United States District Court, M.D. Alabama, Northern Division
PHASE 2A REMEDIAL OPINION ON IMMEDIATE RELIEF FOR
H. THOMPSON, UNITED STATES DISTRICT JUDGE.
long-standing lawsuit, the court previously found that the
Alabama Department of Corrections (ADOC) has failed to
provide adequate mental-health care to inmates in its custody
in violation of the Eighth Amendment to the United States
Constitution. See Braggs v. Dunn, 257
F.Supp.3d 1171 (M.D. Ala. 2017) (Thompson, J.), Braggs v.
Dunn, No. 2:14CV601-MHT, 2019 WL 539050, __ F.Supp.3d __
(M.D. Ala. Feb. 11, 2019) (Thompson, J.). More recently, in
the wake of 15 inmate suicides in a 15-month period, the
plaintiffs asked for immediate suicide-prevention relief. For
reasons that follow, the court concludes that these suicides,
as well as other evidence in the record, show that ADOC
continues to fail to provide adequate suicide-prevention
measures and, thus, subjects inmates to a substantial risk of
serious harm, including self-harm, continued pain and
suffering, and suicide. The risk of suicide is so severe and
imminent that the court must redress it immediately.
Therefore, the court will grant the plaintiffs' motion
for immediate relief by making permanent most provisions of
an interim suicide-prevention agreement that the parties
reached early in this litigation; by adopting, in large
measure, the recommendations proposed by experts for both
parties; and by requiring court monitoring that is limited to
the immediate relief ordered here. By agreement of the
parties, the issue of non-immediate suicide-prevention relief
will be resolved by the court later.
plaintiffs in this class-action lawsuit include a group of
seriously mentally ill state prisoners and the Alabama
Disabilities Advocacy Program (ADAP), which represents
mentally ill prisoners in Alabama. During the liability
trial, and in response to the suicide of class member Jamie
Wallace just days after he testified, the parties agreed to a
series of interim suicide-prevention measures. See
Interim Agreement (doc. no. 1106-1). The court reduced this
‘interim agreement' to an order. See
Interim Relief Order (doc. nos. 1106, 1106-1).
2017, the court issued a liability opinion in which it found
that ADOC's mental-health care for prisoners in its
custody was, “[s]imply put, ... horrendously
inadequate” and violated the Eighth Amendment.
Braggs, 257 F.Supp.3d at 1267. The court more
specifically found that “ADOC's inadequate crisis
care and long-term suicide-prevention measures have created a
substantial risk of serious harm, including self-harm,
suicide, and continued pain and suffering.”
Id. at 1220. The “serious”
suicide-prevention deficiencies identified by the court
included ADOC's failure to provide crisis care to those
who need it; placement of prisoners in crisis in dangerous
and harmful settings, including unsafe crisis cells;
inadequate treatment for prisoners in crisis care; inadequate
monitoring of suicidal prisoners; inappropriate release of
prisoners from suicide watch; and inadequate follow-up care
for prisoners released from suicide watch. See Id.
at 1218-31. Moreover, the court found that these risks are
particularly heightened for prisoners with serious mental
illnesses. “Serious mental illness” (SMI) is a
term of art used in the field of psychiatry which refers to
“a subset of particularly disabling conditions ...
defined by the diagnosis, duration, and severity of the
symptoms.” Id. at 1246. Certain conditions are
always considered SMIs, such as schizophrenia, bipolar
disorder, and major depressive disorder. See id. at
period of months, the court adopted several ‘remedial
orders' regarding mental-health care that touched on
suicide prevention. To fashion a comprehensive
suicide-prevention remedy, the parties agreed to, and the
court accepted, a process whereby Drs. Mary Perrien and
Kathryn Burns, the defendants' and plaintiffs'
correctional mental-health experts, respectively, would
“assess ADOC facilities and operations related to
suicide prevention and provide a report with recommendations
to resolve the constitutional violation determined by the
Court in the Liability Opinion and Order.” Joint Notice
(doc. no. 2014) at 1; Order (doc. no. 2020) (adopting the
parties' plan for assessing suicide-prevention measures).
January 18, 2019, before the parties' experts completed
their report, and in response to a series of suicides, the
plaintiffs filed an emergency motion regarding the placement
of high-risk prisoners in segregation. See Motion
for Preliminary Injunction (doc. no. 2276) at 1. The court
construed it as seeking permanent, albeit immediate, relief.
See Order (doc. no. 2345).
March 8, the experts filed (1) a report with recommendations
for relief, (2) a report identifying a subsection of those
recommendations to be implemented immediately in light of the
recent suicide crisis plaguing ADOC, and (3) case summaries
of many of the recent suicides. See Joint Expert
Report and Recommendations, Immediate Relief Recommendations,
Joint Expert Case Summaries (doc. nos. 2416-1, 2416-4,
2416-2). Their reports were the product of an extensive and
thorough study, in which they reviewed thousands of documents
from ADOC, toured multiple facilities, and interviewed both
prisoners and staff.
March and April, the court held a trial to determine whether
immediate and non-immediate suicide-prevention relief is
needed and, if so, what it should be. The parties and the
court decided during the hearing that the portion of the
hearing on non-immediate suicide-prevention relief would be
continued to a future date. This opinion addresses only
immediate relief in response to the ongoing substantial and
pervasive inadequacies in ADOC's suicide-prevention
efforts, exemplified by the 15 suicides that have occurred
since December 2017.
immediate relief, the plaintiffs first request that the court
enter an order making permanent most of the provisions of the
interim agreement. The agreement addressed licensing of
mental-health professionals; suicide-watch procedures,
including inmates' placement on and discharge from
suicide watch, follow-up appointments upon discharge, and
documentation requirements; and suicide risk assessments,
including a monthly evaluation of assessments.
plaintiffs also request that the court adopt as an order the
experts' second report. This report identifies a
subsection of their recommendations that should be
implemented on an immediate and permanent basis. These
‘immediate relief recommendations' address
suicide-watch follow-ups, referrals to higher levels of care,
preventing discharge from suicide watch to segregation,
training for staff, security checks in segregation,
confidentiality, and immediate life-saving intervention. In
addition, the plaintiffs seek interim monitoring of the
the plaintiffs also argue that the defendants are placing
mentally ill prisoners in units that, while not labelled as
segregation or restrictive housing, impose equally severe
restrictions on out-of-cell time, and the same accompanying
risk of serious harm, particularly suicide. Therefore, they
contend, the court's relief should extend to these
“segregation like” settings.
court heard substantial evidence suggesting that prisoners in
certain units receive very little out-of-cell time. However,
the court needs more time to consider the evidence, and may
decide to solicit additional input from the parties before
deciding this critical issue. Therefore, the court's
findings remain open as to this discrete issue, and the court
will take it up after this opinion is issued.
RECENT SUICIDES 
men in ADOC custody have committed suicide since December 30,
2017, an average of almost one suicide per month. An
examination of their cases illustrates severe and systemic
inadequacies in ADOC's suicide-prevention efforts. Many
of the inadequacies, detailed in the 15 cases below, are
instances of ADOC's pervasive and substantial
noncompliance with the interim agreement and other remedial
measures that they agreed to implement; that is, they are
examples of what ADOC recognized are “systemic failures
to comply with court orders.” Pls. Ex. 2710 at
ADOC0475738. Other inadequacies, while not necessarily
constituting noncompliance with specific remedial orders to
date, show ADOC's failure to live up to its obligations
under the Eighth Amendment. In sum, both types of
deficiencies summarized in the 15 cases below demonstrate
that immediate relief is necessary to address the substantial
risk of serious harm to which prisoners remain exposed.
March 8, 2019, Rashaud Morrissette hanged himself with a belt
in the shower of a segregation unit at Fountain prison.
See Crook Apr. 2, 2019, Trial Tr. (doc. no. 2488) at
184; Pls. Ex. 2661 at ADOC0470542. ADOC's
suicide-prevention failures in his case include that before
entering segregation, he did not receive a critical
preplacement screening for issues such as whether he was at
risk of suicide or had a serious mental illness (SMI).
See Crook Apr. 2, 2019, Trial Tr. (doc. no. 2488) at
185; Burns Apr. 9, 2019, Rough Draft (R.D.) Trial Tr. at 191;
see generally Pls. Ex. 2692.
Holmes killed himself on February 14, 2019, roughly 12 hours
after being transferred from mental-health observation (MHO)
to segregation at Limestone prison. See Burns and
Perrien Apr. 9, 2019, R.D. Trial Tr. at 169, 186. (MHO is a
short-term placement that does not have the same level of
protections as suicide watch.) ADOC's suicide-prevention
failures in his case include (1) not placing him in suicide
watch despite his being suicidal, and (2) placing him in
segregation despite his having a SMI, and without adequately
assessing his suicide risk or referring him for the emergency
mental-health care he needed. Specifically:
• On February 11, 2019, Holmes was improperly placed in
MHO, rather than suicide watch. See Defs. Ex. 3613
at SPA_13585. A “Psychiatrist/CRNP Progress Note”
on February 12 indicates that he had recently become suicidal
after being placed in segregation, and that he had twice
attempted suicide in 2010. Id. at SPA_13582. As
acknowledged by Deborah Crook, ADOC's Director of Mental
Health Services, Holmes met the National Commission on
Correctional Health Care (NCCHC)'s definition of
nonacutely suicidal, and therefore, under the interim
agreement, should have been placed on at least nonacute
suicide watch (rather than MHO), at which point a suicide
risk assessment would have been required. See Crook
Apr. 2, 2019, Trial Tr. (doc. no. 2488) at 55.
• Because he was not placed on suicide watch, he did not
receive a suicide risk assessment. See Id. at 55-56.
Furthermore, the parties' experts, Drs. Burns and
Perrien, flagged that while in MHO, Holmes's contacts
with mental-health staff were conducted inside his cell,
“rather than in a confidential area out of cell.”
Joint Expert Case Summaries (doc. no. 2416-2) at 4; see
also Defs. Ex. 3613 at SPA_13581-84.
• On February 14, he was ordered released from MHO to
segregation per the order of a nurse practitioner who
“wrote no note in the chart explaining the rationale
for this decision or the level of risk assessed.” Joint
Expert Case Summaries (doc. no. 2416-2) at 4. Holmes's
February 13 treatment plan review had stated that he was
“not making progress toward treatment plan goals,
” Defs. Ex. 3613 at SPA_13577; however, suddenly, the
next day, the treatment plan review concluded that he had
“completed treatment goal, ” id. at
SPA_13576; see also Joint Expert Case Summaries
(doc. no. 2416-2) at 4.
• The segregation pre-placement screening completed on
February 14 at 11:45 a.m. noted that Holmes had a SMI, and
that there were “yes” responses to the following
three questions: (1) Are you feeling sad, hopeless, or
depressed? (2) Have you ever intentionally hurt yourself or
attempted suicide? (3) Have you had any serious problems with
a significant other, family member or friend recently?
See Defs. Ex. 3613 at SPA_13571. As noted by the
parties' experts, despite these responses, Holmes
“was not diverted from segregation placement and an
‘urgent' rather than ‘emergent' referral
to mental health was made.” Joint Expert Case Summaries
(doc. no. 2416-2) at 4.
• Later that night, he was discovered hanging from an
overhead light fixture in his segregation cell. See
• Drs. Burns and Perrien concluded that his case
“illustrates the problems with use of MHO rather than
approved suicide watch levels, poor documentation of
rationale for release from watch, failure to generate an
emergency referral to mental health in response to a positive
pre-placement screen and releasing SMI inmates from watch
directly into segregation.” Id.
Gentry hanged himself at the Donaldson prison Residential
Treatment Unit (RTU) on February 6, 2019. ADOC's
suicide-prevention failings include not placing him on
suicide watch despite his making clear that he wanted to die,
not conducting a suicide risk assessment when indicated, and
inadequate review of his suicide. Specifically:
• A few weeks before his death, on January 24, 2019, a
mental-health progress note reported that Gentry had asked a
correctional officer to kill him. See Pls. Ex. 2314
at SPA_13258. In response, he was placed in MHO that day.
See id. As plaintiffs' expert Dr. Burns
testified, the MHO placement was inappropriate, because
“with someone who's actively voicing the wish that
someone kill him, you would expect to start a suicide watch,
either acute or nonacute, but not just mental health
observation status.” Burns Apr. 9. 2019, R.D. Trial Tr.
• Five days into his MHO placement, Gentry continued to
report “auditory hallucinations and a desire for
someone to kill him.” Pls. Ex. 2314 at SPA_13275. His
records indicate that he did not receive a suicide risk
assessment in relation to his MHO placement. See
generally Pls. Ex. 2314.
• On January 31, 2019, Gentry was released from MHO to
the RTU at Donaldson. See Id. at SPA_13235; Joint
Expert Case Summaries (doc. no. 2416-2) at 3. A week later,
on February 6, he was discovered hanging from a light fixture
inside his cell during a security check. See Joint
Expert Case Summaries (doc. no. 2416-2) at 3. The
correctional officers waited several minutes for medical
staff, who upon arriving, told them to remove the sheet from
his neck and initiated CPR. See Id. Dr. Burns
testified that this intervention was inadequate, as the
officers should not have waited for medical staff to arrive
before removing the noose and beginning CPR. See
Burns Apr. 9, 2019, R.D. Trial Tr. at 204. Indeed, both Drs.
Burns and Perrien noted with respect to Gentry's suicide
that correctional officers “need additional training
and drills regarding first aid and responding to hanging
attempts.” Joint Expert Case Summaries (doc. no.
2416-2) at 3. This observation coincides with the
experts' more general recommendation that ADOC policy and
practice be revised to ensure that as soon as two security
staff are present, “CPR should be immediately initiated
while whatever method of suicide is eliminated.” Joint
Expert Report and Recommendations (doc. no. 2416-1) at 29.
• In carrying out their suicide-prevention assessment,
Drs. Burns and Perrien did not receive any medical or
security reviews of the suicide, see Joint Expert
Case Summaries (doc. no. 2416-2) at 3, even though, in their
expert opinion, ADOC must conduct such reviews in cases of
suicides, see Joint Expert Report and
Recommendations (doc. no. 2416-1) at 34. Here, and in the
other cases detailed in this section in which Drs. Burns and
Perrien did not receive medical or security reviews, the
court infers from ADOC's failure to provide the reviews
that either the reviews were never conducted, or that--like
the limited sample of documents reviewing suicides that they
did receive--they were generally inadequate.
Ford killed himself in segregation at Kilby prison on January
16, 2019, following two prior suicide attempts in segregation
in 2018, and less than a month after being released from
suicide watch. See Joint Expert Case Summaries (doc.
no. 2416-2) at 3. ADOC's suicide-prevention failures in
his case include inadequate (1) follow-up mental-health
appointments after release from suicide watch, (2) suicide
risk assessments, and (3) mental-health assessments while in
• In April 2018, while in segregation, Ford set fire to
his cell and attempted to hang himself. See id.;
Pls. Ex. 2309 at SPA_9757. On July 30, he again attempted to
hang himself while in segregation and was placed on suicide
watch. See Pls. Ex. 2309 at SPA_9741.
• Following his release from suicide watch on August 2,
he was placed in segregation, but records indicate that,
following discharge from suicide watch, he did not receive
the required three-, seven-, and 30-day follow-up
appointments. See Id. at SPA_9730; see
generally Pls. Ex. 2309.
• Ford's initial mental-health assessment in
segregation failed to note his history of suicide attempts
and left the “assessment” section blank. See
id. at SPA_9728-29.
• On December 12, he cut his wrist while in segregation,
for which he was charged with a disciplinary violation.
See Id. at SPA_9670.
• Ford was placed on suicide watch on December 12.
See Id. at SPA_9702. A suicide risk assessment on
December 20 stated that he had no recent
“suicidal/self-injurious” behavior or ideation,
even though he had cut his wrist just eight days earlier.
Id. at SPA_9674. He was released from suicide watch
around December 21 and placed back in segregation at Kilby.
See Pls. Ex. 2352 at ADOC0462881; Joint Expert Case
Summaries (doc. no. 2416-2) at 3. Records indicate that, in
contravention of the interim agreement, staff did not
complete the follow-up appointments after his release from
suicide watch. See generally Pls. Ex. 2309; Crook
Apr. 2, 2019, Trial Tr. (doc. no. 2488) at 108; Burns and
Perrien Apr. 9, 2019, R.D. Trial Tr. at 123-24.
• On January 16, 2019, Ford was found hanging from his
segregation cell door. See Pls. Ex. at SPA_9656.
Drs. Burns and Perrien did not receive medical or security
reviews of his suicide. See Joint Expert Case
Summaries (doc. no. 2416-2) at 3. While ADOC conducted a
‘quality improvement' (QI) assessment of the case,
both Drs. Burns and Perrien testified that it did not
constitute an adequate review of the suicide. See
Burns and Perrien Apr. 10, 2019, R.D. Trial Tr. at 114-15.
Abrams committed suicide on January 2, 2019, the same day he
was placed in segregation. Rampant suicide-prevention
failures plagued his case, including failing to place him on
suicide watch when he expressed suicidality, repeatedly
failing to screen him for mental-health issues prior to
placing him in segregation, failing to complete mental-health
appointments due to staffing and SPA_ce shortages, and
failing to immediately initiate life-saving measures when he
was found hanging in his cell. Specifically:
• Records indicate that Abrams was initially held in
segregation between August 23 and December 4, 2018,
see Pls. Ex. 2346 at ADOC0462894-95, without
receiving a segregation preplacement screening, see
generally Pls. Ex. 2304.
• A nursing record from September 3 reported that Abrams
had suicidal thoughts and had told people he was going to
hang himself. See Id. at SPA_9559. Despite being
suicidal, Abrams remained in segregation instead of being
placed on suicide watch, see Id. at SPA_9560, and
did not receive a suicide risk assessment at that point,
see Crook Apr. 2, 2019, Trial Tr. (doc. no. 2488) at
• The segregation initial assessment conducted on
September 4--several days after the seven-day timeframe in
which it should have been completed--failed to mention that
the day before, Abrams had told nursing staff that he was
suicidal. See Pls. Ex. 2304 at SPA_9582-83.
• Records indicate that, while in segregation, SPA_ce
and security staff shortages prevented Abrams from having his
scheduled mental-health appointments on November 20, 27, and
30, and December 4. See Id. at SPA_9601; Joint
Expert Case Summaries (doc. no. 2416-2) at 3.
• On approximately December 21, he was placed on suicide
watch after stating that he was suicidal. See Pls.
Ex. 2304 at SPA_9596, SPA_9599. Apparently, he had gone to
the infirmary to have stab wounds checked on, and then felt
increased anxiety about returning to a particular prison
block. See Id. A mental-health progress note from
December 26 also reported that he had safety concerns and
wanted to change institutions because of a conflict he had
with gang-affiliated inmates due to his sexuality. See
Id. at SPA_9594. His records do not contain a single
crisis treatment plan. See generally Pls. Ex. 2304.
• Abrams was released from suicide watch on December 26,
see Id. at SPA_9571, and sometime between then and
January 2, he was placed in segregation, see Crook
Apr. 2, 2019, Trial Tr. (doc. no. 2488) at 181;
Defendants' Response to Amended Chart (doc. no. 2500-1)
at 14. The records indicate that he did not receive a
segregation preplacement screening. See Crook Apr.
2, 2019, Trial Tr. (doc. no. 2488) at 181-82; see
generally Pls. Ex. 2304. Nor did he receive a three-day
follow-up after being discharged from suicide watch. See
generally Pls. Ex. 2304. The parties' experts noted
that despite his stay on suicide watch, he was not placed on
the mental-health caseload. See Joint Expert Case
Summaries (doc. no. 2416-2) at 3; Pls. Ex. 2305 at SPA_9791.
• The segregation duty post logs indicate that, during
the week running up to his suicide, there were several times
where there was an hour, or even two hours, between security
checks, see Vail Apr. 3, 2019, R.D. Trial Tr. at
149, even though ADOC policy requires that security checks in
segregation be conducted every 30 minutes.
• On January 2, 2019, at approximately 7:00 p.m., more
than an hour after the last security check, see id.,
a correctional officer making a security check discovered
Abrams hanging from a vent cover inside his cell,
see Pls. Ex. 2307 at SPA_10451. At 7:11 a.m., he was
cut down and medical staff initiated CPR, according to one
officer's report. See Id. at SPA_10452.
According to both experts, this emergency response time was
“inadequate to save life, ” as “11 minutes
from discovery to cut down is more than enough time for death
to occur.” Joint Expert Case Summaries (doc. no.
2416-2) at 3.
• Drs. Burns and Perrien did not receive a medical
review. See Id. at 3. ADOC's quality improvement
report stated that there were no areas for improvement in
mental-health treatment or institutional operation, and
recommended no corrective actions. See Pls. Ex. 2305
December 21, 2018, Ryan Rust was discovered in his
segregation cell “sitting on [the] floor with one end
of [a] belt around his neck and the other end tied to a bar
in the window of the cell.” Joint Expert Case Summaries
(doc. no. 2416-2) at 2. His case illustrates ADOC's
failures to complete follow-up appointments after a crisis
placement and to conduct timely security checks in
segregation in the immediate lead-up to a suicide.
• Rust was placed on suicide watch from approximately
November 5 to 16, 2018, see Pls Ex. 2298 at
SPA_9880-81, but his records indicate that he did not receive
any follow-up appointments after his release, see
generally Pls. Ex. 2298.
• Rust attempted to escape and was returned to
segregation on December 20 or 21. See Id. at
SPA_9869, SPA_9872; Joint Expert Case Summaries (doc. no.
2416-2) at 2. On December 21, shortly after his segregation
placement, he was discovered hanging in his cell.
See Joint Expert Case Summaries (doc. no. 2416-2) at
• Prior to his death, Rust had received three separate
segregation pre-placement screenings on December 20 and 21.
See Pls. Ex. 2298 at SPA_9867-74. According to Drs.
Burns and Perrien, the “reason for three pre-placement
screenings was not clear. At best, the three completed
screenings raise questions about inefficiencies in the system
regarding redundant work and/or poor communication among
nursing staff; at worst, they raise concerns regarding the
authenticity and validity of the screenings.” Joint
Expert Case Summaries (doc. no. 2416-2) at 2. As Dr. Burns
elaborated, in the worst-case scenario, it represented
“an attempt to say that the screening was done when the
screening wasn't done, and still very poorly coordinated
because they did it three times.” Burns Apr. 9, 2018,
R.D. Trial Tr. at 190.
• Based on his review of the duty post logs,
plaintiffs' expert Eldon Vail testified that about an
hour passed from the last security check to the time Rust was
discovered hanging. See Vail Apr. 3, 2019, R.D.
Trial. Tr. at 151; see also Pls. Ex. 2662 at
ADOC0469207 (duty post log indicating that more than an hour
• Drs. Burns and Perrien reported inadequate review of
Rust's suicide. Specifically, they stated that they did
not receive a medical review, and that the psychological
autopsy was “limited” and did “not contain
any psychological information.” Joint Expert Case
Summaries (doc. no. 2416-2) at 2. They did receive a document
labeled only “Ryan Chas Rust, ” whose authorship
and purpose was unclear, but did “identify deficiencies
in mental health follow-ups, treatment planning and
November 25, 2018, Kendall Chatter was discovered hanging
from the ceiling of his cell in the temporary holding unit at
Staton prison. ADOC's failures in his case include not
transitioning him from acute to non-acute suicide watch prior
to releasing him from suicide watch, not providing follow-up
appointments after he was released from suicide watch, and
not checking his cell even though he was intensely yelling
and banging on his cell in the immediate lead-up to his
• On November 16, 2018, Chatter cut his right wrist,
possibly after being sexually assaulted. See Defs.
Ex. 3577 at SPA_10176-81. He was placed on acute suicide
watch that same day, see Id. at SPA_10180, and then
released directly to MHO the next day, without any
intervening period on non-acute suicide watch, see
Id. at SPA_10178. He was released from MHO on November
20. See Id. at SPA_10164; Joint Expert Case
Summaries (doc. no. 2416-2) at 2.
• His records indicate that he did not receive three- or
seven-day follow-ups after being released from suicide watch.
Crook Apr. 2, 2019, Trial Tr. (doc. no. 2488) at 35. Director
of Mental Health Services Crook said that the failures to do
the follow-ups were violations of the interim agreement, but
that she did not immediately discover the violations because
no one in her office did a detailed review of his
mental-health records until February 2019, more than two
months after he died. See Id. at 35-40.
• On November 25, Chatter loudly and intensely yelled
and banged against his cell for a prolonged period of time.
See Defs. Ex. 3577 at SPA_10200; Joint Expert Case
Summaries (doc. no. 2416-2) at 2; Pls. Ex. 2401 at SPA_13483.
The correctional shift supervisor instructed his officer to
“just allow him to continue banging and being
disruptive and he would get tired and stop, ” according
to a written reprimand of the supervisor. Pls. Ex. 2401 at
SPA_13483. Shortly after Chatter started making
noise--according to one record, less than an hour later--a
correctional officer distributing meals discovered him
hanging from the ceiling by a sheet tied around his neck.
See Id. at SPA_10200-01.
• ADOC's review of the suicide was inadequate. No
medical or security reviews were provided to Drs. Burns and
Perrien. See Joint Expert Case Summaries (doc. no.
2416-2) at 2. Furthermore, according to the experts, the
“mental health QI review contained little information
and no recommendations for improvement in spite of failing to
provide follow-up after watch placement and failure to
provide an actual mental health assessment after referral
from security 11/14/18. ... The Psychological Autopsy states
both that the treatment plan was up to date and included
goals that were implemented but also states that there were
no goals on the treatment plan because he wasn't on the
mental health caseload.” Id.
Araujo used a sheet to hang himself from a door in his
segregation cell at Limestone prison on November 23, 2018.
Inadequacies in his case include not properly responding to
his request for mental-health attention after he was placed
in segregation, and not adequately reviewing his suicide.
• On October 29, 2018, during his initial mental-health
assessment following placement in segregation, Araujo
requested to be placed on the mental-health caseload and
begin medication. See Pls. Ex. 2291 at SPA_10221-22.
Yet, according to Drs. Burns and Perrien, he was not seen by
mental-health staff prior to his death almost a month later.
See Joint Expert Case Summaries (doc. no. 2416-2) at
• Drs. Burns and Perrien noted that the “QI review
contains no recommendations” and that the psychological
autopsy also “contained little information--and
neglected to note that he wanted [mental-health] help and
asked for it 10/29/18 when seen in seg[regation].”
Barker hanged himself from a vent cover in his cell at St.
Clair prison on September 26, 2018. Deficiencies in his case
include housing him in segregation despite his serious mental
illness (SMI), and inadequate interventions to save his life
after he was discovered hanging. Specifically:
• Despite being flagged as having a SMI, major
depressive disorder, see Pls. Ex. 1758 at
SPA_3343-44, Barker had been housed in segregation for
several months in the lead-up to his suicide, see
Joint Expert Case Summaries (doc. no. 2416-2) at 1.
• On September 1, 2018, mental-health personnel
recommended his administrative referral for removal from
segregation due to his SMI diagnosis, see Pls. Ex.
1758 at SPA_3343-44, but records indicate that he was
released from segregation on September 24, just two days
before his suicide, see Joint Expert Case Summaries
(doc. no. 2416-2) at 1.
• On September 26 at 6:30 p.m., a correctional officer
observed Barker hanging from a vent cover over a toilet in
his cell. See Id. Troublingly, “[n]o actions
[were] taken until 6:36 p.m. when medical [staff] arrived at
which time [they] entered cell, cut prisoner down and began
CPR.” Id. Drs. Burns and Perrien concluded
that the correctional officer response was inadequate
because, as explained above, security officers “must
intervene and begin life-sustaining efforts rather than
waiting for medical, ” and also because the medical
emergency response time of six minutes was inadequate.
• Drs. Burns and Perrien did not receive security or
medical reviews of the suicide, and the mental-health review
“was cursory and found no problems and no areas for
Wolfinger was discovered hanging in his segregation cell at
Fountain prison on August 22, 2018, less than a month after
cutting his wrist and being placed in acute suicide watch.
His case shows ADOC's failure to provide adequate
treatment following release from suicide watch to
segregation, the falsification of security logs and failure
to conduct security checks in segregation in the time
immediately leading up to his suicide, and the failure to
initiate life-saving measures immediately when he was
• Wolfinger's records state that on July 26, 2018,
he was placed on acute suicide watch after attempting suicide
by cutting his left wrist with a razor blade. See
Pls. Ex. 1823 at SPA_4134, SPA_4187-90. He remained on acute
suicide watch until July 31, see Id. at SPA_4167,
when he was placed on nonacute suicide watch, id. at
• On August 3, he was discharged from nonacute suicide
watch to segregation. See Burns Dec. 7, 2018, Trial
Tr. (doc. no. 2256) at 117; Pls. Ex. 1823 at SPA_4155,
SPA_4163. The records indicate that he did not receive
adequate follow-ups after his release from suicide watch.
See Burns Dec. 7, 2018, Trial Tr. (doc. no. 2256) at
119; see generally Pls. Ex. 1823.
• According to Dr. Burns, Wolfinger's suicide risk
was elevated by ADOC's failure to provide adequate
treatment to him when he was returned to segregation.
See Burns Dec. 7, 2018, Trial Tr. (doc. no. 2256) at
• The night of Wolfinger's death, the correctional
officer assigned to conduct security checks every 30 minutes
in Wolfinger's area of segregation not only failed to do
a single check, but also put false information in his duty
post log indicating that he had completed the required
checks, according to an ADOC memorandum discussing
disciplinary action against the officer. See Pls.
Ex. 2403 at SPA_13487. The memorandum states that the
correctional officer's actions “resulted in”
Wolfinger's death. Id. at SPA_13488.
• On August 22, around 1:00 a.m., Wolfinger was
discovered hanging in his cell. See id. Drs. Burns
and Perrien reported that the immediate intervention was
inadequate: he was “discovered hanging at 12:57 a.m.,
” but “there was no intervention except to call
for assistance which arrived at 1:03 a.m. No intervention
until others arrived and then he was cut down and taken to
HCU [the health care unit], arriving there at 1:08 a.m. LPNs
attempted CPR and ambulance was called.” Joint Expert
Case Summaries (doc. no. 2416-2) at 2.
• Drs. Burns and Perrien also criticized the inadequate
reviews of Wolfinger's suicide. No medical review was
provided; the QI program review did not make any
recommendations; the psychological autopsy provided no
additional analysis or information. See id.
3, 2018, Jeffery Borden, who had been diagnosed with
schizoaffective disorder, hanged himself on death row at
Holman prison. See Pls. Ex. 1643 at ADOC0424844. His
case is an example of ADOC failing to adequately intervene
with potential life-saving measures and inadequately
completing a suicide incident review. Specifically:
• Neither the correctional officers who originally found
him hanging nor the nurse that later arrived at the scene
attempted CPR or other life-saving efforts. See
Joint Expert Case Summaries (doc. no. 2416-2) at 1; Pls. Ex.
1760 at SPA_2965.
• Drs. Burns and Perrien did not receive a medical or
security review. See Joint Expert Case Summaries
(doc. no. 2416-2) at 1.
12, 2018, “[w]ithin 1 day of being released from MHO to
a housing unit where he expressed concern for his safety from
other inmates, ” Timothy Chumney “was discovered
hanging in his [segregation] cell having tied a bed sheet to
a cell window and then around his neck.” Id.
ADOC's failures in his case include inadequate treatment
planning, not placing him on suicide watch even though he was
found to have a moderate risk of suicide, and an inadequate
review of his suicide. Specifically:
• On May 7, 2018, Chumney was determined to be at a
“moderate” risk for suicide, after telling
medical staff that he had suicidal ideation at night and
would rather harm himself than have someone else harm him.
Pls. Ex. 1646 at ADOC0425086. That same day, however, he was
admitted to MHO instead of suicide watch. See Id. at
• On May 11, Chumney was discharged from MHO. See
Id. at ADOC0425011. The next day, at approximately 3:05
a.m., correctional officers conducting security rounds
discovered him hanging from his segregation cell window in
Limestone prison. See Pls. Ex. 1780 at SPA_3144;
Joint Expert Case Summaries (doc. no. 2416-2) at 1.
• Dr. Burns and Perrien criticized that no “CPR,
actual medical assessment or life-sustaining measures [were]
attempted. LPN responding to the emergency said to leave him
in the cell on the unit and called the physician to pronounce
him dead. Hours later, the deputy coroner arrived and
‘confirmed inmate Chumney deceased.'” Joint
Expert Case Summaries (doc. no. 2416-2) at 1.
• ADOC also inadequately reviewed his suicide. Drs.
Burns and Perrien did not receive medical or security
reviews; the mental-health QI program review had no criticism
or recommendation for anyone; the psychological autopsy
revealed no additional or substantive information. See
• Drs. Burns and Perrien further criticized that there
was “[n]o transitional care planned; treatment plan
called only for a monthly contact with treatment coordinator
and quarterly appointment with CRNP, ” and there was
“[n]o plan to follow more closely (or intervene to
prevent placement in [segregation] based on his anxiety and
time Robert Martinez took his life on March 31, 2018, he had
been in segregation at St. Clair prison for more than one
year. Pls. Ex. 1493 at ADOC0420976-77. In his case,
ADOC's failures included not conducting security rounds
in segregation and not timely cutting him down when he was
• Two weeks before his death, he told mental-health
staff that he was “doing real bad” and needed to
go to a psychiatric ward. Id. at ADOC0421023. ADOC
left him in segregation and failed to connect him with
• Correctional officers failed to conduct security
checks in Martinez's unit for at least two hours during
the morning of his suicide. See A.A. Apr. 23, 2018,
R.D. Trial Tr. at 203-04.
• When ADOC staff discovered Martinez hanging from a
sheet tied to a vent in his cell, they waited more than 30
minutes before cutting him down, a delay that, in the
experts' words, was “inexcusable and
inhumane.” Joint Expert Case Summaries (doc. no.
2416-2) at 1.
died on March 2, 2018, as the result of a head injury he
sustained when attempting to hang himself in segregation at
Holman prison on February 26. See Joint Expert Case
Summaries (doc. no. 2416-2) at 1; Stewart Apr. 23, 2018,
Trial Tr. (doc. no. 1797) at 57. The failures by ADOC in his
case include not placing him on suicide watch after he was
found attempting to hang himself and said he wanted to kill
himself, and not completing suicide risk assessments or
providing follow-up appointments after releasing him from
• A nursing record from December 27, 2017 reports that
Thornton said he wanted to kill himself, had been found
attempting to hang himself, had suicidal thoughts, and
auditory hallucinations of “kill, kill yourself.”
Pls. Ex. 1489 at ADOC0420855. Drs. Burns and Perrien
testified that he should have been placed on suicide watch;
however, the records show that he was improperly placed on
MHO. See Id. at ADOC0420856; Burns and Perrien Apr.
9, 2019, R.D. Trial Tr. at 89-90.
• The records indicate that no suicide risk assessment
was conducted at the time. See Burns Apr. 9, 2019,
R.D. Trial Tr. at 90; see generally Pls. Ex. 1489.
• Records indicate that he did not receive adequate
follow-up appointments after release from MHO on January 2 or
3, 2018, given that he actually should have been placed on
suicide watch rather than MHO. See Joint Expert Case
Summaries (doc. no. 2416-2) at 1; Burns and Perrien Apr. 9,
2019, R.D. Trial Tr. at 121; Stewart Apr. 23, 2018, Trial Tr.
(doc. no. 1797) at 50-52; see generally Pls. Ex.
• Thornton was again transferred to crisis watch on
February 22, and then released back to segregation on
February 23. See Stewart Apr. 23, 2018, Trial Tr.
(doc. no. 1797) at 6-8. The records indicate that Thornton
did not receive follow-up attention after his release from
crisis watch. See Joint Expert Case Summaries (doc.
no. 2416-2) at 1.
• On February 26, as a correctional officer was speaking
to him in his segregation cell, Thornton “stepped onto
his bed put a shoe string around his neck and was hanging
from the light fixture, ” according to an incident
report. Pls. Ex. 1488 at ADOC0421089. As the officer reached
toward Thornton, the string broke, and Thornton fell and hit
his head on the floor. See id.
• Officers put Thornton in a wheelchair and took him to
the medical unit. See Id. According to Drs. Burns
and Perrien, the “decision to place him in wheelchair
after sustaining head/neck injury rather than a back board
and/or calling for medical to respond requires further review
and supports need for additional and on-going first aid
training for correctional staff.” Joint Expert Case
Summaries (doc. no. 2416-2) at 1.
• Thornton died on March 2 as a result of the head
injury. See id.; Stewart Apr. 23, 2018, Trial Tr.
(doc. no. 1797) at 57; Pls. Ex. 1488 at ADOC0421089.
• ADOC's review of the incident leading to
Thornton's death was inadequate. Drs. Burns and Perrien
did not receive a medical or security review; and the
mental-health QI review “did not identify any issues
with mental health's failure to provide any follow-up to
Mr. Thornton after crisis placements.” Joint Expert
Case Summaries (doc. no. 2416-2) at 1.
• Ultimately, Dr. Burns testified that she believed
ADOC's noncompliance with the interim agreement increased
Thornton's risk of suicide, “because the risk was
never measured and quantified, in spite of multiple crisis
placements, ” and “there doesn't appear to be
any effort to reduce that risk.” Burns Dec. 7, 2019,
Trial Tr. (doc. no. 2256) at 106.
December 30, 2017, Ben McClure jumped to his death from the
top tier of a dormitory at Limestone prison. See
Incident Report (doc. no. 1966-25) at 2; Pls. Ex. 1669 at
ADOC0424820. ADOC failed to initiate immediate life-saving
measures. Namely, the officers who found McClure did not
immediately conduct CPR, but rather waited until Licensed
Practice Nurses arrived a few minutes later, according to
ADOC reports. See Id. As stated above, Drs. Burns
and Perrien emphasized that CPR should be initiated as soon
as two security staff are present, regardless of whether
medical staff has arrived. See Joint Expert Report
and Recommendations (doc. no. 2416-1) at 29.
Permanent Injunction Requirements
plaintiffs' emergency motion seeks permanent, albeit
immediate, relief. To obtain a permanent injunction,
plaintiffs must show: (1) actual success on the merits; (2)
that irreparable injury will be suffered without an
injunction; (3) that the threatened injury outweighs any
damage the proposed injunction may cause the opposing party;
and (4) that the injunction, if issued, would not be adverse
to public interest. See Klay v. United Healthgroup,
Inc., 376 F.3d 1092, 1097 (11th Cir. 2004). As discussed
below, the plaintiffs meet all these requirements.
Success on the Merits: Eighth Amendment Violation
plaintiffs satisfy the first requirement for a permanent
injunction because they have succeeded on the merits of their
claim. To prevail on an Eighth Amendment challenge,
plaintiffs must show that: (1) objectively, prisoners had
serious medical needs and either had already been harmed or
were subject to a substantial risk of serious harm; and (2)
subjectively, the defendants acted with deliberate
indifference to that harm or risk of harm; that is, they knew
and disregarded an excessive risk to inmate health or safety.
See Braggs, 257 F.Supp.3d at 1189. As the court held
in 2017, the plaintiffs met this standard and therefore
established an Eighth Amendment violation, given that
ADOC's mental-health care for prisoners was,
“[s]imply put, ... horrendously inadequate”
Braggs, 257 F.Supp.3d at 1267. The court
specifically found that ADOC's inadequate suicide
prevention contributed to the Eighth Amendment violation. As
the court explained, deficient suicide prevention--both alone
and in combination with six other
inadequacies--"subject[s] mentally ill prisoners to
actual harm and a substantial risk of serious harm.”
Id. at 1193. ADOC's suicide prevention was found
to be deficient in multiple ways. These included inadequately
identifying prisoners at risk of suicide, providing
inadequate treatment and monitoring to at-risk prisoners, as
well as inappropriately releasing prisoners from suicide
watch and not giving them follow-up care. See Id. at
1220, 1231. Additionally, the court found that the
“skyrocketing number of suicides within ADOC, the
majority of which occurred in segregation, ” reflected
the “combined effect” of inadequate screening for
the impact of segregation on mental health, and inadequate
treatment and monitoring in segregation units. Id.
extensively detailed in the liability opinion, see
Id. at 1194-1200, ADOC's “persistent and
severe shortages” of mental-health and correctional
staff significantly contributed to all these deficiencies.
Id. at 1268. Since then, the court has repeatedly
reaffirmed the centrality of mental-health and correctional
understaffing to ADOC's mental-health care failings, and
thus, Eighth Amendment violations. See Braggs, 2019
WL 539050, __ F.Supp.3d __ at *5, 9-10; Braggs v.
Dunn, 2019 WL 78949, __ F.Supp.3d __ at *1 (M.D. Ala.
Jan. 2, 2019) (Thompson, J.); Braggs v. Dunn, 2018
WL 5410915, __ F.Supp.3d __ at *1 (M.D. Ala. Oct. 29, 2018)
addition to the liability findings, the court further finds
that the substantial and pervasive deficiencies identified in
the 15 recent suicides demonstrate that ADOC's
suicide-prevention efforts remain inadequate and continue to
contribute to the ongoing Eighth Amendment violation
originally found in the liability opinion. ADOC still has
serious deficiencies in the identification of prisoners at
risk of suicide, as well as in their treatment, monitoring,
and follow-up care. The deficiencies include:
• Failing to place suicidal prisoners on suicide watch;
• Failing to conduct suicide risk assessments;
• Failing to appropriately monitor prisoners on suicide
• Failing to put prisoners on the mental-health caseload
• Inadequate treatment planning; and
• Inadequate follow-up treatment after release from
segregation practices also continue to suffer from the
serious flaws the court found in the 2017 liability opinion,
• Inadequate screening of prisoners for suicidality and
SMIs prior to placing them in segregation;
• Placing prisoners with SMIs in segregation absent
extenuating circumstances; and
• Failing to conduct 30-minute security checks in
segregation, and failing to make sure the checks are
these serious inadequacies in segregation practices, it is
unsurprising that, similar to the liability opinion's
finding in June 2017 that the “majority” of
suicides occurred in segregation, Braggs, 257
F.Supp.3d at 1245, ADOC recognized nearly two years later, in
March 2019, that the “majority of inmates who committed
suicide within ADOC have been men who were alone in a
restrictive housing cell,  after being released from
suicide watch.” Pls. Ex. 2706 (Mar. 21, 2019,
Daniels's memorandum announcing directive).
continuing deficiencies are compounded by ADOC's repeated
failure to initiate immediate life-saving measures. Although
not identified in the liability opinion, this problem clearly
exacerbates ADOC's inadequate suicide-prevention efforts,
and illustrates that prisoners remain at substantial risk of
mental-health and correctional understaffing remains a
driving force behind the suicide-prevention deficiencies
putting prisons at risk. As of December 2018, ADOC reported
that 62 % of correctional officer positions were vacant,
see March 2019 Quarterly Staffing Report (doc no.
2386-1) at 3, and as of September 2018, 23.6 % of the
mental-health positions were vacant, see December
2018 Quarterly Staffing Report (doc. no. 2378-1) at 9.
Commissioner Dunn admitted that ADOC is currently
“struggling” to comply with court orders because
of inadequate staffing levels, Dunn Apr. 1, 2019, R.D. Trial
Tr. at 145, and affirmed that understaffing remains one of
the problems driving the spike in suicides. See id.
addition to showing that prisoners remain at a substantial
risk of serious harm, the 15 suicides also demonstrate that
ADOC continues to act with deliberate indifference. As found
in the liability opinion, “the state of the
mental-health care system is itself evidence of ADOC's
disregard of harm and risk of harm: in spite of ... notice of
the actual harm and substantial risks of serious harm posed
by the identified inadequacies in mental-health care, those
inadequacies have persisted for years and years.”
Braggs, 257 F.Supp.3d at 1256. Almost two years
since the court wrote those words, the inadequacies continue
to persist, as evidenced by the problems pervading the recent
many of the inadequacies in the 15 suicides constitute
noncompliance with the interim agreement and other remedial
orders that ADOC agreed to implement. ADOC's continued
inability to carry out the terms of the interim agreement and
other remedial measures thus far illustrates “a
striking indifference by ADOC to a substantial risk of
serious harm.” Id. at 1264.
ADOC's inadequate internal review of the 15 suicides
shows ongoing deliberate indifference, just like the court
originally found deliberate indifference in part because ADOC
had “done vanishingly little to exercise oversight of
the provision” of mental-health care. Id. at
1257. ADOC's ongoing broader failures to self-monitor are
also extensively detailed in the monitoring section below.
has recently adopted some promising measures to improve
suicide prevention, such as the March 21, 2019, announcement
by ADOC Deputy Commissioner Charles Daniels of a directive
generally prohibiting the release of inmates from suicide
watch directly to segregation. See Pls. Ex. 2706.
However, as elaborated below, the measures are insufficient
to address the scope of a problem that is many years in the
making, and, as they were implemented quite recently, it
remains to be seen whether they will even be effectively
implemented. In any case, several of the key measures came
only after the spike in suicides had taken more than
a dozen lives, and after the plaintiffs brought
attention the problem by requesting emergency relief. Put
differently, the measures have been too little, too late.
conclude, while the liability findings by themselves would
justify the relief ordered here, the court's additional
factual findings concerning inadequate suicide prevention in
the 15 recent suicides underscores that the constitutional
violation remains ongoing and requires immediate relief.
Accordingly, the plaintiffs satisfy the first requirement for
a permanent injunction.
this in mind, the court will now briefly discuss why the
plaintiffs satisfy the remaining requirements for a permanent
Remaining Permanent Injunction Requirements
plaintiffs meet the remaining three requirements for a
permanent injunction. As to the second requirement, the
immediate and substantial risk of suicide, as reflected in
the recent wave of suicides, satisfies the irreparable harm
inquiry. As to the third, the threatened injury absent an
injunction--a higher risk of suicides and
suffering--outweighs any harm the injunction would cause,
particularly because, as discussed below, the defendants
agree with or claim to be already enacting most of the
measures the plaintiffs seek. Finally, an injunction is not
adverse to the public interest, for ...