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Findings and Recommendations 7 findings
F1
Failure to follow procedures Some OCSD staff allowed prohibited behavior by inmates and failed to follow written procedures, including: Properly conducting inmate counts Adequately searching plumbing tunnels, if at all Conducting comprehensive roof searches Requiring inmates remove and cease the use of tenting and ratlines Adequately searching inside the cells themselves Accounting for all prison-issued sheets and clothing
Related Recommendations (1)
R1
The Board of Supervisors should continue to provide funding as outlined in the five year plan and provide additional funding in the FY 2017-18 budget as detailed in the OCSD Jail Hardening Report to complete the long term hardening requirements requested by OCSD.
F2
Lack of funding Several past Grand Jury reports noted inadequacies in the video monitoring of inmates in the CMJ and recommended funding to update the systems. Such funding was not approved by the Board of Supervisors until the 2014-2015 fiscal year. In addition to the need to update video equipment, the OCSD has identified, and this Grand Jury agrees, that there is a crucial need to fund the following: An updated computer system to facilitate the completion of RFI throughout all of the jails Full body scanners and/or additional metal detectors Additional CCTV systems including coverage of all roof areas and an employee who monitors the screens in real time Additional fencing on the CMJ roof Funding of these additional security components will greatly enhance security. Failure to provide funding for these needed upgrades will severely impact the OCSD’s ability to prevent future escapes.
Related Recommendations (1)
R2
of the publication of this report, the executive staff of the OCSD should develop and implement guidelines to hold all staff accountable for conducting their jobs in compliance with policy and procedures manual.
F3
Lack of supervision/oversight There was a lack of consistent supervision at the CMJ to ensure that counts, searches, and logs required by the policy and procedures manual were completed and conducted according to procedure. There was an overall lack of consistent supervision regarding plumbing tunnel checks, tenting and ratlines, inmate counts, etc. Additionally, inmate count issues raised by sergeants and lieutenants were not acted upon by executive jail management. Subsequently, OCSD has adequately addressed the personnel issues that led to the escape.
Related Recommendations (1)
R3
The OCSD should continue to review the department’s policy and procedures manual on at least an annual basis, update it when necessary, and expeditiously inform all personnel of changes to the manual.
F4
Confusion within the policy and procedures manual The OCSD policy and procedures manual regarding inmate counts was confusing. Proper count procedure was defined in an inconsistent manner in the manual. The improper count procedure contributed to the escape and the approximately 15 hour delay in discovering the missing inmates. The escapees’ awareness of insufficient accounting for inmates’ whereabouts may have played a part in the inmate’s planning the escape. It should be noted that the OCSD is in the process of revising appropriate sections of the policy and procedures manual to eliminate any confusion and inconsistencies regarding proper count procedure.
Related Recommendations (1)
R4
of the publication of this report, the OCSD should put additional security guidelines in place to provide security screening for visitors, vendors and staff. This may include full body scans, additional metal detectors, bag searches, and additional drug detection dogs.
F5
Inadequate security measures The security measures in place at the CMJ were inadequate. Non-sworn employees, vendors, and visitors entering the facility were not searched on a regular basis, nor were their belongings; sworn deputies are never searched. With proper search and security measures in place and in practice, including searching all non-sworn employees and visitors, accounting for tools brought in by maintenance workers and vendors, and documenting the disposal of contraband, the tools that aided in the January 2016 escape would likely not have been smuggled into the jail.
Related Recommendations (1)
R5
of the publication of this report, the OCSD should institute a policy of on-going training of all staff members to ensure understanding of jail policy and procedures. REQUIRED RESPONSES The California Penal Code §933 requires the governing body of any public agency which the Grand Jury has reviewed, and about which it has issued a final report, to comment to the Presiding Judge of the Superior Court on the findings and recommendations pertaining to matters under the control of the governing body. Such comment shall be made no later than 90 days after the Grand Jury publishes its report (filed with the Clerk of the Court). Additionally, in the case of a report containing findings and recommendations pertaining to a department or agency headed by an elected County official (e.g. District Attorney, Sheriff, etc.), such elected County official shall comment on the findings and recommendations pertaining to the matters under that elected official’s control to the Presiding Judge with an information copy sent to the Board of Supervisors. Furthermore, California Penal Code Section §933.05 (a), (b), (c), details, as follows, the manner in which such comment(s) are to be made: (a) As to each Grand Jury finding, the responding person or entity shall indicate one of the following: (1) The respondent agrees with the finding (2) The respondent disagrees wholly or partially with the finding, in which case the response shall specify the portion of the finding that is disputed and shall include an explanation of the reasons therefore. (b) As to each Grand Jury recommendation, the responding person or entity shall report one of the following actions: (1) The recommendation has been implemented, with a summary regarding the implemented action. (2) The recommendation has not yet been implemented, but will be implemented in the future, with a time frame for implementation. (3) The recommendation requires further analysis, with an explanation and the scope and parameters of an analysis or study, and a time frame for the matter to be prepared for discussion by the officer or head of the agency or department being investigated or reviewed, including the governing body of the public agency when applicable. This time frame shall not exceed six months from the date of publication of the Grand Jury report. (4) The recommendation will not be implemented because it is not warranted or is not reasonable, with an explanation therefore. (c) If a finding or recommendation of the Grand Jury addresses budgetary or personnel matters of a county agency or department headed by an elected officer, both the agency or department head and the Board of Supervisors shall respond if requested by the Grand Jury, but the response of the Board of Supervisors shall address only those budgetary /or personnel matters over which it has some decision making authority. The response of the elected agency or department head shall address all aspects of the findings or recommendations affecting his or her agency or department. Comments to the Presiding Judge of the Superior Court in compliance with Penal Code section §933.05 are required from: Responses are required from the following governing body of the date of publication of this report: Orange County Board of Supervisors (Finding 2; Recommendation 1) Responses are required from the following elected agency or department head of the date of publication of this report: Orange County Sheriff/Coroner (Findings 1, 3-7; Recommendations 2-5)
F6
Training All deputies receive additional training upon assignment to the CMJ. Because of inconsistencies within the policy and procedures manual regarding inmate counts and a long-standing practice of conducting “paper counts”, incoming deputies to the CMJ were trained improperly. Changes to the manual were not adequately emphasized. Regular reminders of appropriate security and safety procedures were likewise inadequate.
No recommendations for this finding
F7
Unanswered Questions The Grand Jury is concerned that there are key elements that remain unanswered about the escape, such as the silence of the 38 inmates who shared housing with the escapees, and what tools were used and how they were brought in, leaving doubts as to whether the current upgrades will prevent future escapes. Penal Code §933 and §933.05 require governing bodies and elected officials to which a report is directed to respond to findings and recommendations. Responses are requested from departments of local agencies and their non-elected department heads. RECOMMENDATIONS In accordance with California Penal Code Sections 933 and 933.05, the 2016-2017 Grand Jury requires (or, as noted, requests) responses from each agency affected by the recommendations presented in this section. The responses are to be submitted to the Presiding Judge of the Superior Court. Based on its investigation of the jailhouse escape of 2016 in Orange County, the 2016-2017 Orange County Grand Jury makes the following five recommendations:
No recommendations for this finding
Conclusions 1
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CL1On January 22, 2016, three inmates escaped from the CMJ. Problems in daily operations and with the dated design of the CMJ were magnified by the escape. The OCSD had to address these problems quickly, and it did so in varying degrees. The actions taken immediately after the escape included: securing points of exit used by the escapees, re-emphasizing proper procedures 2016-2017 Orange County Grand Jury Page 10 The Great Escape - Never Again? for conducting inmate counts, and instituting a tool inventory and a visitor search protocol. Additionally, a Jail Hardening Team was formed to develop a plan to make physical improvements to the facility to ensure that future escapes would not occur. The plan to further harden the CMJ includes two phases: short-term improvements, which could be instituted within six months, and long-term improvements for additional hardening, as funds became available. After conducting a comprehensive study, problems with both supervision and training became obvious. Lack of compliance with existing policies and procedures by various OCSD personnel at all levels was the primary factor responsible for the escape. In many instances, required inmate count procedures were not followed; mandatory jail inspections of various areas were not conducted; appropriate training was not provided; supervision of deputies by management was inadequate; and confusing language in relevant sections of the OCSD’s policy and procedures manual all combined to enable the escape to occur. Subsequent to the escape, the OCSD has taken various steps to harden the jail both physically and procedurally. CCTV cameras, motion detectors, improved lighting, additional fencing and modifications to grates and bars have been installed. Proper count and inspection procedures have been clarified and emphasized, and management supervision has been significantly increased. Tighter controls on visitors and areas for potential contraband smuggling have been implemented. However, several questions remain unanswered. It is baffling how and who provided the inmates with the cutting tools used in the escape, and how the inmates executed the months-long planning and execution of the escape from a dormitory cell housing 38 other prisoners without one of those prisoners informing deputies of the escape. Without answers to these questions, the OCSD may never be able to fully close the book on this escape or ensure it won’t happen again. A $10.9 million five year plan to update video equipment, to be funded annually, was adopted by the Board of Supervisors after the 2013/14 Grand Jury report. It remains for the Board of Supervisors to continue to provide funding for the implementation of this plan and provide additional funding for security measures deemed necessary by the OCSD and identified by several previous Grand Juries. Without additional security measures being addressed, the public cannot feel fully confident that everything that can be done has been done to prevent future escapes.
Agency Responses 1
Government agencies' official responses to this report's findings and recommendations. Click on a response to see the structured breakdown.
No Responses Found 1
Government entities assigned to respond to this report. No response documents have been linked in our database.
Orange County Board of Supervisors
Elected County Office