When the Metro Council commissioned the report in April 2022, six people had died in Louisville Metro Corrections Department custody. Since then, seven more people have died, bringing the total to 13 people dead in 15 months.
Former FBI agent and attorney David Beyer, who led the investigation, conducted 60 interviews, four visits to the training academy, five visits to the jail facilities, and reviews of nine of the in-custody deaths. The report identifies five main issues that played a role in the deaths:
- Past leadership shortcomings
- Antiquated facility
- Staffing woes
- Failure to follow basic security protocols
- Poor coordination and communication between medical staff and corrections officers
In previous discussions of the report, Louisville officials primarily focused on the facility, which was deemed “woefully inadequate.” Mayor Craig Greenberg also announced updates to the intake process which would include a mental health screening.
The report also showed that there is a lack of accountability at the jail for people who violate policies, sometimes chronically. Among other issues, the report identified more than 3,700 disciplinary cases for correctional officers over a five-year period. Roughly two-thirds were for time and attendance-related issues, but a significant number of them were also for insubordination or performance issues.
The jail has a severe staff shortage, which facilities across the country are experiencing. The report also pointed to numerous environmental issues, including a culture that tolerates sexual harassment and low morale.
Dr. Homer Venters is a former chief medical officer of New York City’s correction department and now works as a federal court-appointed monitor of jail and prison health care. He said that health care is sometimes the first to go when a jail is understaffed.
“Once people are incarcerated, however, they have an absolute right to receive adequate health services. And when staffing is lower than what it should be, their ability to access health services can be difficult or even non-existent,” Venters said. “They may have a health crisis, a physical or behavioral health crisis, and nobody's there to respond to them. Nobody's there to get them the care they need.”
In the report, Beyer called for recruiting more staff and more quality training. The report states that the staff is under “pressures to hire numbers rather than quality candidates.”
The report also found large gaps in documentation of medical conditions and procedures. Venters said obscurity and lack of documentation is sometimes baked into the culture of carceral institutions and make further reforms difficult.
Venters said jail officers are usually the first responders for emergencies. The report noted some staff did not have basic medical training or the ability to communicate quickly with medical staff. In one case, the report states, correctional officers entered a cell where Stephanie Dunbar had attempted suicide. Instead of trying to resuscitate her, the officers slapped her bare feet, gave her verbal commands and “hard sternal rubs” for nearly a minute.
During his tours of the jail, Beyer said he also observed a failure to adhere to basic security procedures, like properly locking doors or routinely checking on those incarcerated.
Wanda Bertram, a spokesperson for the Prison Policy Initiative, said medical concerns are almost never going to be top of mind in a carceral setting. She said cities should focus on reducing jail populations to help lessen staffing woes rather than putting more money into them.
“When you reduce the number of people who are locked up, you free up capacity for staff to deal with the medical needs of people who are in there, who really do need to be in there,” Bertram said.
