Jail report must spur changes
Allegheny County’s just-released report, by the National Commission on Correctional Health Care, raises serious questions about a rash of prisoner deaths in Allegheny County — most notably, how many of them could have been prevented? The report doesn’t — and couldn’t — answer that question, but it depicts enough troubling details to shake the complacency out of any county official, including inadequate emergency care, missed prisoner checks, questionable logbook entries and a dearth of documentation in prisoner death reviews.
The NCCHC Technical Assistance Report for the Allegheny County Jail, which reviewed 27 prisoner deaths from January 2017, should become a call for new leadership at the jail, and for action on overdue changes in the health care and treatment of Allegheny County prisoners. Allegheny County’s 17 prisoner deaths since April 2020 represent one of the highest per-capita rates in the nation.
County Executive Rich Fitzgerald authorized the review in August.
Troubling lapses
In several of the deaths, the report cited problems with guard tours and logbook chronologies. In the 2017 suicide of a 33-year-old woman, the NCCHC report, noting “discoloration from ligature marks on her neck,” stated the woman appeared to have been hanging “for some time,” though logbooks indicated officers checked on the prisoner. Tampering with logbooks is a criminal offense; the report said “disciplinary action was taken.”
In the 2020 death of a 55-year-old man due to asphyxia from food obstruction, “a guard tour was logged out of time sequence with the medical emergency.” This might indicate entries are made before they are completed. In addition, a sergeant ordered the camera turned off before entering the cell.
In the 2021 death of a 74-year-old male, the unit logbook did not match the timeline of the video review for guard tours. The medical emergency was not in chronological order in the logbook, indicating the tours were logged before they were completed.
Guard tours were also missed in the 2017 suicide of a 39-year-old man.
In a 2017 suicide by hanging, officers failed to give a 62-year-old man CPR .
In 2018, a man requested a psychological evaluation for his 57-year-old ex-wife the day before she committed suicide by hanging. Nothing in the critical incident report, however, indicated what services, if any, she received the day she killed herself.
The report also noted “minimal information” from jail reports or public media sources about a 59year-old male’s death from heart failure in 2018.
Obscuring deaths
Allegheny County is not only doing an inadequate job of documenting prisoner deaths, but also skirting federal law on reporting them. The county doesn’t count certain prisoners
who died after they were transported to a hospital. In doing so, local jail officials are withholding information from the state and federal government that could help prevent such tragedies.
Last year’s death of Anthony G. Talotta, 57, an intellectually disabled man from Monroeville, was not reported, even to the Allegheny County Jail Oversight Board. County officials argued that Mr. Talotta’s death was exempt from federal reporting requirements because he was released from custody before he died in the hospital.
The letter and spirit of the federal Death in Custody Reporting Act is clear: An inmate who is transferred to a medical facility and dies there shouldbe reported.
An incomplete picture
NCCHC staff members interviewed various jail administrators, nurses and mental health providers. They also reviewed custody documents, medical examiner reports, incident reports and logs. But team members did not report interviewing any of the jail’s 1,500 prisoners; nor did they interview former prisoners. That gives the report less credibility.
The report also noted the jail’s strained relationship with employees and the Jail Oversight Board. But if county officials want the help of the Jail Oversight Board in carrying out changes recommended in the NCCHC report, they shouldn’t have handed the report to Jail Oversight Board members at the start of their monthly meeting on March 2, giving them no chance to review and discuss it. The date on the final report says Dec. 27. Why didn’t the county release it before?
It’s unlikely that Mr. Fitzgerald can replace Mr. Harper before the county executive’s term ends at year’s end. Who would want the job, knowing the next county executive might replace him or her?
In his final year, Mr. Fitzgerald must make the jail one of his top priorities and lead a communitywide campaign to clean it up.