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Escape of Inmate James Nero from DC General Hospital
Executive Summary
November 8, 1999




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Office of the Inspector General
Charles C. Maddox, Esq. Inspector General

Executive Summary

Concerning the Results of Office of the Inspector General
Investigation 2000-0054

On October 24, 1999, Mayor Anthony Williams directed the Inspector General to initiate an investigation into the circumstances surrounding the October 23, 1999, escape of James NERO, an inmate incarcerated at the District of Columbia Detention Facility.

On October 23, 1999, at approximately 12:45 am, inmate NERO complained of seizure like symptoms allegedly associated with a prior head injury. It was determined that he should be taken to D.C. General Hospital for examination and treatment. At approximately 1 1:50 am, NERO was taken to the hospital, which is located adjacent to the Correctional Facility. He was examined and treated in the emergency room, and at approximately 7:20 am, after being placed in a medical discharge status, NERO overpowered his escort officer, took his revolver, and escaped from the hospital. A gunfight ensued, during which 41 shots were fired, and resulted in inmate NERO being recaptured after having been wounded with two gunshots.

Based on the foregoing, this Office focused its investigation on the following two issues:

1. Whether there exist adequate policies and procedures governing the care and custody of DCDF inmates while on escorted trips outside the Correctional Facility.

At the time of NERO's escape, three relevant District of Columbia Department of Corrections (DOC) policies were in effect regarding the security procedures to be followed for all escorted trips: (1) DOC Department Order 4910.1D, dated November 15, 1991; (2) D.C. Detention Facility Post Order- Medical Outpost, dated March 12, 1996 and D.C. Detention Facility Post Order - Medical Escorts, dated May 12, 1993. Based on a careful review of these policies and procedures, this Office has concluded that the regulations have two serious deficiencies: first, they do not provide for specific classification for pre-trial detainees such as NERO; and second, they are materially confusing and vague. With respect to the first deficiency, we are unable to find any regulation that specifically classifies pre-trial inmates. In our view, the lack of a formal classification policy for pre-trial detainees is a serious deficiency that could easily contribute to an inmate's escape. According to the section in Department Order 4910.1D, addressing "Security Procedures", the proper level of escort that must accompany an inmate is based exclusively on his classification. If the classification of an inmate is unclear, per force, the proper level of escort is unclear. We could identify nothing, other than a word-of-mouth policy, that specifies the proper classification of pre-trial inmates Interestingly, the October 1999 Report to the Attorney General by the Corrections Trustee regarding the Leo Gonzales WRIGHT case, notes this identical deficiency and quotes a Report by Dr. James Austin that made the very same point in 1996. The trustee's Report concludes that the problem was not corrected after the 1996 Report.

With respect to the second deficiency, we found the DOC regulations to be uniformly imprecise and confusing - especially with regard to the proper use of restraints. For example, the Detention Facility Medical Outpost Order states that an inmate must be escorted to the bathroom "in restraints." The Order does not, however, specify the exact type(s) of restraints to be used - in leg irons, in handcuffs, or both? The same Order goes on to emphasize, "NEVER REMOVE RESTRAINTS WITH OUT A BACKUP OFFICER." Does this mean all restraints? In other words, if an inmate is in both handcuffs and leg irons, must there be a second Officer present if either restraint is removed and the other left in place? The Order also states, "Never leave the inmate alone." Does this mean that the Officer must remain in a secure restroom while an inmate uses it, or is it sufficient to remain outside the door? Again, the regulation is unclear. Furthermore, similar imprecision can be found throughout the Medical Escorts Order and Department Order 4910.1D.

We believe that if employees are to be held responsible for implementing regulations in situations where death or grievous bodily harm can result from an incorrect interpretation, the regulations must be absolutely clear.

2. Whether such policies and procedures were followed prior to the escape, and if not. who was accountable.

Investigation into this issue determined that the Correctional Officer, assigned to guard NERO while he was at the emergency room of D.C. General Hospital, violated the Department of Corrections policies and procedures contained in Departmental Order 4910.1D and D.C. Detention Facility's Medical Outpost and Medical Escort Post Orders. Specifically, we have concluded that despite specific notations of "full restraints" ... "two officers" ... and "caution" on the Department of Corrections Health Services Transportation Request, the officer violated Detention Facility Escort Order of May 12, 1993, by allowing NERO to spend "an extended period" (circa 2:00 am until 730 am) in the emergency room, without the presence of a backup officer, during which NERO was neither handcuffed nor "handcuffed to the stationary bedframe" (as required by the Escort Order). Additionally, the officer violated the Medical Outpost Order of March 12, 1996, by not maintaining "direct vision and control of [NERO] at all times" insofar as he repeatedly allowed NERO to be alone in the restroom, and more significantly, in that he allowed NERO to make his final trip to the restroom entirely unescorted while he (officer) was making a telephone call. We have concluded that it was this final dereliction, by which the officer allowed NERO to go unescorted and unhandcuffed to the restroom (while the officer was on the telephone) that led directly to NERO surprising the officer, overpowering him, seizing his weapon and escaping. We consider this to be a material and serious breach of the regulations that could easily have led to death or grievous injury of an innocent person(s).

Based on the results of this investigation, the Inspector General recommends:

  • That the Department of Corrections implement immediately a classification system for all pre-trial detainees.
  • That the Department of Corrections take immediate steps to review and clarify all relevant regulations germane to the comments set forth in the first finding of this Report.
  • That the Director, Department of Corrections take appropriate disciplinary action against the Officer in accordance with the range of penalties (reprimand to termination) set forth in DPM 1618.1.4.

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