Deeply alarming. Dangerous. Ill-equipped.
This is how a long-awaited, independent audit described the Milwaukee County Jail's practices and training around suicide prevention — one of the many concerns that has drawn public outcry in recent years and spurred the monthslong investigation.
The audit highlighted systemic issues ranging from "dangerous" suicide watch practices and challenges to administering mental health care as well as poor leadership oversight, the ongoing critical staffing shortage and inmate overcrowding.
Calls for an audit of the jail sounded after six in-custody deaths between 2022 and 2023, including two confirmed suicides.
In June 2022,21-year-old Brieon Greenstrangled himself with a phone cord while in a booking area.
That December, 20-year-old Cilivea Thyrionchoked to death on an adult diaperwhile housed in a special needs pod.
The Milwaukee County Sheriff's Office initially reported that Octaviano Juarez-Corro's cause of death was unknown, with no signs of injury or trauma at the time. However, records later revealed evidence suggesting he had strangled himself.
Shortly after, the County Board called on an internal review from the Milwaukee County Sheriff's Office, which oversees operations at the jail.
With members of the board and local advocates dissatisfied with the information provided, an external audit was voted on and approved to address concerns about circumstances surrounding the deaths and conditions at the facility. The board later selected a Texas-based firm, Creative Corrections, to conduct the audit.
This is not the first time the jail has been under scrutiny. Shortly after the jail opened in 1992 it faced a class-action lawsuit over concerns about crowding and its impacts on the facility's safety and conditions.
The lawsuit resulted in a consent decree in 2001. To address concerns about the crowding, the jail was required to cap the number of pre-trial inmates, restrict time spent in the booking process to 30 hours, and face mandated court oversight of health care services provided.
In 2022, a Journal Sentinel investigation revealed significant staffing shortages at the jail during former Sheriff Earnell Lucas Lucas' tenure placed the facility in violation of the consent decree. During that period, reports surfaced of hunger strikes, lockdowns lasting over 21 hours, a lack of mental health care, and delays in providing medication.
A year later and under the leadership of current Sheriff Denita Ball, the jail remained in crisis as it continued to navigate unprecedented worker shortages and long lockdowns.
'Deeply alarming' suicide watch and prevention practices
While the audit noted that the jail's mental health department "stands out as a significant strength" and the facility and its medical care provider, Wellpath, comply with mental health and suicide prevention policies, it said suicide prevention practices were a huge point of concern.
During the on-site portion of the audit, investigators reported the unsafe practice of handcuffing suicidal inmates to benches during booking, and in some cases for extended periods that exceeded eight hours.
Investigators also reported witnessing a suicide attempt in which an inmate, handcuffed to a bench in the booking area, used a leg restraint attached to the floor to try and strangle himself.
The audit called the practice "deeply alarming" and said it should be stopped.
"The reliance on this method reveals a critical lack of training and understanding regarding appropriate suicide watch protocols," the report said.
The audit also reported concerns about current constant observation practices that posed a "serious safety risk." In one case an inmate was placed in a cell with the lights off and a dirty, scratched window. The officer in charge of monitoring the individual sat at a table 15 feet away and that "it was impossible for the auditor to see into the cell, rendering 'constant' observation ineffective."
Many suicide watch cells were reported to have broken lights, internal switches that could be tampered with and pose a safety risk, as well as windows that had been scratched or had obstructed visibility due to taped items on glass.
Auditors recommended using ankle bracelets to provide constant vital signs to monitor inmates and notify staff when changes occur as a way to enhance one-on-one observation practices.
Auditors found that leadership failed to review critical incidents, particularly those involving self-harm, during their weekly meetings to discuss operational issues. The report called the oversight "a significant missed opportunity" to identify systemic issues, to improve staff response to critical incidents and safety conditions, and prevent future cases of self-harm.
The audit noted that probationary staff received insufficient training in managing inmates with mental health conditions, suicide awareness and prevention, and de-escalation techniques, leaving them "ill-equipped to handle the complex and demanding realities of the correctional environment, potentially jeopardizing the safety and security of both staff and occupants."
Training records reviewed during the audit indicated that Wellpath contractors had not received their required annual suicide prevention training and that correctional staff had limited knowledge of suicide risk factors as well as procedures and protocols when handling at-risk inmates.
The Sheriff's Office has not yet commented on the audit.
Contact Vanessa Swales at 414-308-5881 orvswales@gannett.com. Follow her on X@Vanessa_Swales.
