Jail Audit Finds ‘Deeply Alarming’ Suicide Policies

Milwaukee County Jail. Photo by Jeramey Jannene.

A third-party audit of the Milwaukee County Jail has found serious problems with current jail operations and policies by the Milwaukee County Sheriff‘s Office (MCSO) and its health care provider Wellpath, LLC.

The audit was conducted by Texas-based Creative Corrections, LLC. The firm recently provided the county with a report, obtained by Urban Milwaukee, documenting “deeply alarming” policies for suicide prevention, inefficient use of mental health resources, insufficient training, understaffing, overcrowding and a lack of internal oversight.

The Milwaukee County Board pursued an independent audit after a series of suicides and deaths in the jail during the past few years. In approving the audit, supervisors were particularly interested in the jail’s suicide prevention and mental health policies, and recommendations for improving them. Creative Corrections was selected, in part, for its extensive experience with mental health in correctional settings.

Urban Milwaukee has requested comment from the sheriff’s office on the auditor’s report, but has not received a response as of publishing.

The audit ultimately found a number of critical breakdowns and gaps in the facility’s suicide prevention policies. Notably, auditors found that jail staff routinely handcuff suicidal occupants to benches in the booking area, sometimes for more than eight hours at a time. At one point during the review they even observed one of these occupants attempt to commit suicide by wrapping an unused leg restraint around their neck. The incident was caught by jail staff walking past.

“The practice of handcuffing individuals on suicide watch to benches in the MCJ booking area was deeply alarming and should be stopped,” the report states. 

The practice underscores an issue that pops up throughout the report: improper or inadequate training for jail staff. In particular, the report said, handcuffing suicidal occupants to benches in the booking area, “reveals a critical lack of training and understanding regarding appropriate suicide watch protocols.”

Suicide watch is also overused in the facility, according to the auditors. An average of 36 occupants a week are placed on a 24-hour suicide watch, bypassing alternative interventions and the expertise of clinicians working in the jail. The overuse is driven by Wellpath’s policy for potentially suicidal occupants, which requires 24-hour stays in suicide watch.

“This rigid policy undermines the clinical judgment of mental health professionals and could potentially harm occupants who were not considered suicidal,” the auditors determined.

The problem is exacerbated by the “inefficient and potentially harmful” policy allowing any jail staff to place an individual on suicide watch without an assessment by a mental health professional, even when one is available.

“This approach triggers a cascade of clinical encounters and documentation that can consume 14 hours of staff time over 90 days for a single 24-hour watch,” the report states, adding that it can cause staff to miss “crucial opportunities” to determine if suicide watch is needed and explore other interventions like counseling.

Beyond their overuse, suicide watch facilities and practices also raise significant issues, according to the audit. Current policy in the jail requires one-to-one observation for anyone on suicide watch, or one staff member for each occupant. However, after reviewing the procedures in place, the auditors determined, “The current method appears ineffective and essentially no different than standard 15-minute checks.”

Auditors saw an occupant on suicide watch placed in dirty cell, with the lights off and a scratched and dirty window. The officer assigned to observation sat 15 feet away behind a glass wall. “From this position, it was impossible for the auditor to see into the cell, rendering the ‘constant’ observation ineffective,” the report states.

Auditors found rooms where the lights didn’t work at all and the windows were so scratched and marked they could no longer see through them. In these instances, jail staff interacted with the occupants primarily by speaking through the food slot in the door. The lights switches are also on the inside of the rooms, which prevents staff from controlling lighting and creates opportunities for potentially suicidal occupants to electrocute themselves, according to the report.

Overall, the auditors found a “critical gap” in suicide prevention training for jail staff. Because there isn’t annual training for staff and contractors, new staff are often on the job before receiving any formal suicide prevention training.

The auditors did commend the mental health professionals at the jail and the efforts made by the MCSO to improve mental health staffing. The investments made in mental health resources have already yielded better outcomes for suicide prevention and mental health in the jail, according to the report.

“They provide a dynamic program, evidenced by extensive contact hours and high occupant satisfaction with care,” according to the report. “However, the heavy burden of documentation and clinical time associated with suicide watch protocols limits their capacity to expand group therapy and other valuable services.”

One barrier to day-to-day mental health in the jail is the living conditions. The auditors found cells are often dirty and covered in graffiti, particularly in the women’s housing unit. These conditions, coupled with a lack of space for programming and treatment, do not create a conducive setting for mental health resources.

While the auditors found there was robust communication between Wellpath staff and jail staff, they did find a breakdown of communication in one critical area. During weekly meetings between Wellpath and jail leadership, recent critical incidents, including suicide attempts, were not discussed.

“This oversight represents a significant missed opportunity to identify systemic issues, improve staff response to critical incidents, enhance occupant safety, and potentially prevent future occurrences of self-harm.” 

For every flaw or concern reported by the auditors a recommendation for correcting them was also included. They also noted that jail leadership is “receptive to suggestions and eager to implement positive changes” that could solve some of the issues flagged by the report.

“Despite uncovering several concerning safety and security risks at MCJ, Creative Corrections SMEs also acknowledge the facility’s efforts to implement positive changes,” the report states. “This suggests that while significant challenges remain, MCJ is actively working towards improvement.”