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GOVERNMENT OF THE DISTRICT
Office of the Inspector General
Charles C. Maddox, Esq. Inspector General
Concerning the Results of Office of the Inspector General
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
Based on the foregoing, this Office focused its investigation on the following two
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
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
- 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
- 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.