U.S. Department of Justice Findings Report on Georgia Prisons

Investigation of

Georgia Prisons

U.S. Department of Justice

Civil Rights Division

U.S. Attorney’s Offices for the

Northern, Middle, and Southern

Districts of Georgia

i

October 1, 2024

TABLE OF CONTENTS

TABLE OF CONTENTS ………………………………………………………………………….. i

EXECUTIVE SUMMARY ………………………………………………………………………… 3

INTRODUCTION …………………………………………………………………………………… 4

INVESTIGATION …………………………………………………………………………………. 11

DEFICIENT CONDITIONS IDENTIFIED …………………………………………………. 14

A. The State of Georgia Fails to Reasonably Protect Incarcerated Persons

from Violence. ……………………………………………………………………………. 14

1.

GDC allows frequent, pervasive violence in the prisons, resulting in

serious bodily harm and, in some cases, death. ………………………. 14

2.

GDC’s grossly inadequate staffing leaves incarcerated persons

unsupervised and ha

mpers staff’s ability to respond to violence. .. 23

3.

GDC prisons are unsafe due to aging and inadequately maintained

facilities and failure to ensure adequate lock, tool, and key controls.

…………………………………………………………………………………………. 34

4.

GDC’s ineffective c lassification and housing systems expose

incarcerated persons to an unreasonable risk of violence. ………… 38

5.

GDC fails to control violence even in its segregated housing units

and exposes incarcerated persons to an unreasonable risk of harm

due to its inappropriate use of segregated housing. …………………. 42

6.

GDC fails to control illegal and violent activity by gangs and other

security threat groups. …………………………………………………………. 46

7.

GDC fails to control weapons, drugs, and other dangerous

contraband in its prisons. ……………………………………………………… 50

8.

GDC fails to report and investigate serious incidents of harm and

dangerous activities. ……………………………………………………………. 53

9.

GDC does not reasonably protect incarcerated individuals, including

LGBTI individuals, from sexual harm. …………………………………….. 60

B. The State is Deliberately Indifferent to the Risk of Harm to Incarcerated

Persons. ……………………………………………………………………………………. 73

i

MINIMUM REMEDIAL MEASURES ……………………………………………………….. 79

A. Short-Term and Immediate Measures ………………………………………………. 79

B. Violence: Long-Term Measures ……………………………………………………… 85

C. Sexual Safety: Long-Term Measures ………………………………………………. 91

CONCLUSION…………………………………………………………………………………….. 93

ii

EXECUTIVE SUMMARY

After an extensive investigation in Georgia’s prisons housing people at the medium-

and close-security levels, the Department of Justice (the Department or DOJ)

concludes that there is reasonable cause to believe that the State of Georgia and the

Georgia Department of Corrections (GDC) violate the Eighth Amendment of the United

States Constitution. Consistent with the Civil Rights of Institutionalized Persons Act, 42

U.S.C. §§ 1997 et seq. (CRIPA), we provide this Report to notify Georgia and GDC

(collectively, the State) of the Department’s conclusions, the facts supporting those

conclusions, and the minimum remedial measures necessary to address the violations

identified.

FINDINGS

The United States provides notice of the following conditions in

Georgia’s prisons:

•

Protection from Violence and Harm: The State fails to

protect incarcerated people from violence and harm by other

incarcerated people in violation of the Eighth Amendment.

•

Protection from Sexual Harm: The State fails to protect

incarcerated people from harm caused by sexual violence in

violation of the Eighth Amendment. The State also fails to

adequately protect people who are lesbian, gay, bisexual,

transgender, and intersex (LGBTI) from a substantial risk of

serious harm from sexual violence and abuse by staff and

other incarcerated people.

The State is deliberately indifferent to these unsafe conditions. The constitutional

violations are exacerbated by serious deficiencies in staffing and supervision, physical

condition and security of the facilities, classification and housing, management of

gangs and other security threat groups, control of weapons and other contraband, and

incident reporting, response, and investigations. The State has known about the

unsafe conditions for years and has failed to take reasonable measures to address

them.

3

INTRODUCTION

Georgia is the eighth most populous state in the United States and has the fourth-

highest state prison population. GDC incarcerates almost 50,000 people in 34 state-

operated prisons and 4 private prisons, ranging in capacity from fewer than 500 to

more than 2,500 beds.1 Staffing levels vary across the prisons, with correctional officer

(CO) vacancy rates around 50% systemwide and over 70% at ten of the largest

facilities. More than 32,000 of GDC’s population are classified as medium security and

more than 11,600 are classified as close security.2 Almost 10,000 are serving a life

sentence or life without parole; for the remainder, the average sentence is about 26

years. GDC operates on a $1.2 billion budget. GDC’s Commissioner is Tyrone Oliver,

who took over the role in January 2023, after Timothy Ward, the previous

Commissioner, retired. The Commissioner reports to the State Board of Corrections

and the Governor.3

The incarcerated population in the Georgia prison system faces a substantial risk of

serious harm due to failing systems, particularly security staffing, that have been in

decline for decades. In the 1980s, Georgia funded prison expansion to address a

rising incarcerated population and overcrowding, despite the Commissioner at the time

explaining there were not enough COs to meet current needs. This trend, of an

increasing incarcerated population and decreasing number of staff, continued into the

1990s. Over the past twenty years, Georgia consolidated some of its prisons, but

these actions failed to address the gap between the increasing size of its incarcerated

population and unmet staffing needs.

Since 1990, Georgia’s prison population has more than doubled, from a little over

21,000 in 1990 to almost 50,000. GDC’s average CO vacancy rate was 49.3% in

2021, 56.3% in 2022, and 52.5% in 2023. At many of GDC’s close- and medium-

security prisons with high levels of violence, CO vacancy rates are even higher. In

1 These 38 prisons include men’s medium- and close-security prisons, men’s “special mission” prisons (a

designation for prisons with programs, medical services, or other special purposes), and women’s prisons.

In addition to these prisons, GDC houses thousands more people in its custody or supervision at lower-

security facilities, including transitional centers and drug treatment facilities. See Georgia Dep’t of

Corrections, Facilities Division, https://perma.cc/DU5Y-W2YF, and https://perma.cc/Q6M4-6SBQ.

2 See Georgia Dep’t of Corrections, Inmate Statistical Profile at 25 (June 1, 2024), https://perma.cc/P8EG­

C5V2. According to GDC, persons incarcerated at the “close” security level “are escape risks, have

assault histories, and may have detainers for other serious crimes on file,” and “require supervision at all

times by a correctional officer.” Those incarcerated at the “medium” security level constitute the largest

category of GDC’s population, and “have no major adjustment problems and most may work outside the

prison fence, but must be under constant supervision.” See Georgia Dep’t of Corrections, About GDC,

State Prisons, https://perma.cc/9M7Z-DUCH.

3 See generally Georgia Dep’t of Corrections, Fiscal Year 2023 Annual Report, https://perma.cc/NA52­

CVBP.

4

December 2023, 18 GDC prisons had CO vacancy rates over 60%, and 10 of those

were over 70%. The circumstances within Georgia’s prisons did not develop overnight,

but rather represent decades of inaction to address a growing and changing

incarcerated population, aging infrastructure, and years of declining staffing rates.4

With security staffing at such low levels, violence and criminal activity proliferate in the

prisons. GDC fails to stop and to respond appropriately to homicides, life-threatening

and other serious violence, and sexual abuse – including of vulnerable LGBTI people.

Over the six-year period from 2018 through 2023, GDC reported a total of 142

homicides in its prisons, with 48 in the first three years and a 95.8% increase in the

latter three years, with 94 homicides.5 The rate of homicides in GDC prisons

significantly exceeds the most recent available national data on homicide rates in

correctional facilities. Although GDC’s security staffing saw some modest increases in

2023, with more staff hires than separations for the first time in years, violence

remained a constant, with a record 35 homicides in the prisons by GDC’s own reported

numbers.

4 In recent years, GDC has taken some steps to address its problems, including advertising heavily for

staff, raising starting salaries, sending tactical teams into facilities to conduct occasional large-scale

shakedowns, and closing or renovating dilapidated prisons. As discussed later in this report, see infra at

§ B, these steps have been inadequate to address the scope of the harm and risk of harm to incarcerated

people and employees in GDC’s prisons.

5 From 2011 through 2018, the number of homicides systemwide in GDC prisons never exceeded nine

deaths annually. As discussed elsewhere in this Findings Report, see infra § A.8.a, we identified multiple

additional homicide deaths that GDC’s reported homicide totals fail to reflect.

5

Our investigation identified hundreds of serious incidents that highlight the systemic

violence and chaos in GDC prisons, and GDC’s failure to control it. For example, in

December 2023, GDC experienced five homicides at four different prisons, and serious

incidents at other facilities:

•

On December 8, 2023, a man in his 20s was stabbed in the barber shop at

Central State Prison, in Bibb County. He received treatment at an outside

hospital, returned to the prison, and died after going into cardiac arrest

“secondary to stabbing” on December 18.

•

The day before, December 17, 2023, another man, also in his 20s, was stabbed

to death at Central State Prison; three other incarcerated people were criminally

charged in early January 2024 for their roles in his death.

•

Between these two deadly stabbings at Central, two other homicides occurred

in other prisons. On December 10, 2023, an incarcerated person died after an

altercation with his cellmate at Macon State Prison. On December 13, 2023, an

incarcerated person at Coastal State Prison, in Chatham County, died after an

altercation with other incarcerated persons; he was due to be released in 2024.

•

On December 22, an incarcerated person at Telfair State Prison died after an

altercation with another incarcerated person.

Meanwhile, December also saw stabbings and other serious incidents at other GDC

prisons, including Phillips State Prison, where an incarcerated person whom DOJ had

interviewed earlier in 2023 required hospitalization on December 17 for six or more

stab wounds. That same day, video circulated on social media of a fire, set by

incarcerated persons on the previous day, in the sallyport area of a housing unit at

Phillips, while incarcerated people milled around the sallyport.6

Violent incidents occur across the GDC system, placing thousands of incarcerated

people at substantial risk of serious harm on an ongoing basis. For example:

•

Within a span of just four days in April 2023, two brutal assaults occurred in the

same facility, Smith State Prison, one resulting in a man’s death. On April 5,

2023, an incarcerated man at Smith was discovered dead, possibly strangled to

death by his roommate in a segregated housing unit. The local coroner noted

the body was badly decomposed, and the man likely had been dead for over

two days. Four days prior, on April 1, 2023, another person was assaulted by

multiple incarcerated people inside another hous

ing unit at Smith. A video of

6 See Human and Civil Rights Coalition of Georgia, Phillips State Prison, Facebook (Dec. 18, 2023),

https://perma.cc/RGF6-ETQ4. GDC records confirmed the basic details of this incident.

6

the assault was uploaded onto social media, where the victim’s family saw it

several days later.7 The video showed an incarcerated man sitting on the floor

with his hands tied behind his back before a group of men around him punched,

kicked, and stabbed him.

•

On January 6, 2023, a Lieutenant at the Georgia Diagnostic and Classification

Prison (GDCP) responded to a housing unit, where the officer initially found two

wounded incarcerated people. One appeared to have broken an ankle after

jumping from the upper-level walkway in an effort to escape being assaulted;

the other had a laceration to his jaw. Both were transported to a local hospital.

Six other incarcerated persons from that housing unit also had assault wounds,

including stabbings and lacerations. Subsequently, on the same shift, the same

Lieutenant found another stabbing victim in a different housing unit. In all, six

individuals were hospitalized that evening from the attacks, which involved

gang members attacking rival gang members. Just four nights later, four more

incarcerated persons were assaulted in the same housing unit. One of the

victims described his attack involving two masked men, one brandishing a

“sword” that he used to whip the victim while demanding his CashApp account.

A group of other incarcerated persons continued to assault the victim with fists

and kicks as he escaped from his cell.8 This victim and three others were

eventually identified by staff the next morning when a Lieutenant observed

them with bruises and swollen faces. All the identified victims were transported

to a hospital after giving statements indicating they had been attacked by gang

members while in their cells.

GDC also fails to protect incarcerated persons from sexual abuse. The lack of staffing,

supervision, and systems of accountability gives predators easy access to potential

victims. People who are LGBTI are especially vulnerable.9 Gangs that run housing

units often target LGBTI individuals with physical and sexual violence. LGBTI

individuals described being beaten and stabbed by others in their housing unit because

of their LGBTI status. Others reported receiving threats of violence if they did not leave

the housing unit. Yet despite their vulnerability, GDC does not adequately screen,

classify, or track LGBTI individuals to ensure their safety. Instead of making

7 See Cody Alcorn, Inmates Record Horrific Beating, Stabbing Inside Georgia Prison Cell, 11 ALIVE (Apr. 8,

2023, 12:03 AM), https://perma.cc/K2EN-HXAM.

8 See David Morris, Assault on Human Rights, MEDIUM (Dec. 13, 2023), https://perma.cc/4EDW-TFDJ.

9 We recognize that preferred terminology changes over time, and that more inclusive language (e.g.,

LGBTQI+) may be preferable to many. When we notified Georgia that we were expanding this

investigation, we used the term “LGBTI,” intending that term to include gender non-conforming, queer, and

other identities. We are using the term LGBTI in this report for consistency, with the same inclusive intent.

7

individualized assessments, GDC houses transgender women with men based on their

external genitalia despite the risk this poses to their safety. Investigations into sexual

abuse allegations are poor and frequently fail to include witness interviews or consider

video evidence. And corrective actions to prevent sexual abuse or protect LGBTI

individuals at a systemic level seldom if ever occur. A few examples illustrate these

deficiencies:

•

In May 2022, a gay man reported that his cellmate had sexually

assaulted him. The man stated that the cellmate was part of a gang that

had ordered the cellmate to get the man out of his cell because he was

openly gay. The cellmate injured the man in the shoulder with a shank,

tied him up, and raped him. GDC investigators deemed the matter

unsubstantiated. It appears GDC took no further action even though

both men told investigators that the man was tied up, that the men had

had sexual relations, and that a gang had ordered the cellmate to drive

the man out of his cell.

•

In March 2021, a transgender woman alleged that an incarcerated man

in the protective custody unit ordered her to provide oral sex through the

chow port in her cell door to receive a meal tray. The man denied

sexual contact with the transgender woman but admitted to taking drugs

and sticking his erect penis through the chow port. We received no

evidence that GDC took any administrative action despite the man’s

admission.

Violence and other criminal activity in the prisons affect the surrounding communities

as well. The GDC system has become a hub for known criminal activity, endangering

other incarcerated persons and the public. District Attorneys from around the state told

DOJ that the proportion of violent crimes originating in the prisons, including homicides,

has increased in recent years, straining prosecutorial resources. In the past six years,

hundreds of GDC officers have been arrested on criminal charges arising out of acts

committed in or in relation to the prisons, including acts with victims outside of the

prisons. The vast majority were contraband-related arrests, while other charges

involved violence, extortion, or sexual assault; gangs with members inside and outside

the prisons often played a role. Dozens more officers have been fired, but not

arrested, for misconduct related to contraband.10

10 See, e.g., Danny Robbins & Carrie Teegardin, Hundreds of GA prison employees had a lucrative side

hustle: They aided prisoners’ criminal schemes, ATLANTA JOURNAL-CONSTITUTION, Sept. 21, 2023,

https://perma.cc/2P34-TXLJ.

8

Scores of people have been charged or sentenced in high-profile criminal cases arising

from illegal conduct by people incarcerated by GDC or by GDC employees that has

harmed people inside and outside the prisons. For example:

•

In February 2023, the Warden of Smith State Prison, Brian Adams, was

arrested on Georgia RICO charges for his alleged involvement in an extensive

drug-smuggling conspiracy led by a person who was incarcerated at Smith.

The same incarcerated man who allegedly led the drug smuggling conspiracy

also has been charged with directing two 2021 murders in the local community:

the death of an elderly citizen, Bobby Kicklighter, in his home in January 2021,

in an apparently botched murder-for-hire intended to target a different person;

and the death of a young woman, Jessica Gerling, a former GDC CO, in June

2021.

•

In September 2023, Thomas White, a person incarcerated by GDC, pleaded

guilty to multiple criminal counts related to his involvement in a drive-by

shooting that occurred in 2021 near a Marietta, Georgia, apartment complex

and Home Depot. The shooting resulted in significant damage to two separate

units, both of which were occupied at the time of the shooting. Mr. White

allegedly used a contraband cellphone from a GDC prison to instruct his free-

world associates to commit the shooting.11

•

In November 2023, 23 individuals, including several individuals who were

incarcerated at six different GDC prisons, were charged in a sweeping federal

indictment stemming from gang-related crimes committed from inside and

outside GDC prisons, including stabbings and assaults committed at multiple

GDC prisons in 2020; a shooting death in the outside community in Griffin,

Georgia, in December 2020; and a home arson in early 2021. In a separate

federal indictment the same month, a man incarcerated at Telfair State Prison

received a federal sentence of life in prison for his leadership role in a massive,

gang-related drug trafficking conspiracy; a GDC CO also was sentenced in the

case, for helping to move contraband into the prison at the incarcerated gang

leader’s direction.

11 Press Release, Georgia Office of the Att’y Gen., Four Convicted in Gang-Related Drive-by Shooting

(Nov. 1, 2023), https://perma.cc/M82F-VKKW.

9

Violence in the Georgia prisons has reached a crisis level. The state fails to take

appropriate steps to provide reasonable protection from harm to the incarcerated

people in its custody. It also fails to protect the public from criminal activities which spill

into the outside community. Those incarcerated by GDC, as well as GDC employees,

face an ongoing substantial risk of serious harm due to the lack of controls and violent

conditions in Georgia’s prisons.

10

INVESTIGATION

In 2016, DOJ launched a statewide investigation into whether GDC adequately

protects incarcerated persons who are LGBTI from sexual abuse by staff and by other

incarcerated persons. In 2021, DOJ expanded the investigation to include protection of

all incarcerated persons at the medium- and close-security-level prisons from violence

by other incarcerated persons.

The investigation was conducted jointly by the Special Litigation Section of the Civil

Rights Division of the United States Department of Justice and the United States

Attorney’s Offices for the Northern, Middle, and Southern Districts of Georgia. As part

of the investigation, between 2022 and 2023, DOJ visited 17 GDC prisons – about half

of the state prisons – representing geographically and demographically diverse areas

throughout the state and correctional populations that are the focus of this

investigation.12 DOJ conducted hundreds of private, one-on-one interviews with

incarcerated persons and many more brief conversations while touring the facilities;

conducted several dozen interviews with GDC facility staff, investigators, and executive

leadership; conducted additional interviews with local coroners, first responders,

prosecutors, and employees from other Georgia state agencies; and reviewed tens of

thousands of records from GDC, other Georgia state agencies, and third-party entities

such as local coroners, EMS providers, and community stakeholders. We also

reviewed thousands of additional records, including documents from third parties and

stakeholders, court records from third-party cases, historical sources, and public

reports.

We worked with four highly qualified expert consultants in conducting this investigation.

One is a former high-level state corrections official with decades of experience working

in and running state prisons. One is a former law enforcement official who served in a

leadership role in a large county jail system, with expertise in data analysis, policy

implementation, and staffing assessments. Two are certified Prison Rape Elimination

Act13 (PREA) auditors with specialized expertise in sexual safety in correctional

environments, one of whom served as a former inspector general of a state prison

system, and both of whom bring expertise in policy development, training, and special

12 As part of this investigation, DOJ visited the following prisons in 2022 and 2023: Lee Arrendale State

Prison, Ware State Prison, Hays State Prison, Walker State Prison, Calhoun State Prison, Pulaski State

Prison, Baldwin State Prison, Georgia Diagnostic and Classification Prison, Macon State Prison, Coastal

State Prison, Smith State Prison, Telfair State Prison, Rogers State Prison, Dooly State Prison, Wilcox

State Prison, Phillips State Prison, and Augusta State Medical Prison.

13 34 U.S.C. § 30301 et seq. The regulations implemented to enforce PREA, 28 C.F.R. part 115 et seq.,

collectively referred to as the PREA Standards, require zero tolerance for sexual abuse and sexual

harassment of incarcerated persons, and detail a series of policy and practice reforms aimed at reducing

correctional sexual abuse and sexual harassment and ensuring adequate response thereto.

11

12

considerations affecting incarcerated persons who identify as LGBTI or gender non-

conforming.

Shortly after launching the expanded investigation in September 2021, DOJ issued a

first request for documents to GDC. GDC refused to produce most of the requested

materials until mid-2023, after DOJ issued an administrative subpoena and sought and

obtained court enforcement of the subpoena. GDC also severely limited DOJ’s access

to its prison facilities and to staff interviews until the district court entered a protective

order for the documents DOJ had subpoenaed. Prior to the court’s entry of the

protective order, GDC restricted DOJ’s access to areas of the prisons accessible to

incarcerated persons and facilitated interviews with incarcerated persons but not with

staff.

Even after GDC began to produce the requested records, we encountered challenges

in gathering documents. GDC ultimately produced records sufficient for DOJ to make

findings, but the agency delayed or objected to production of some of the material,

including investigation records. We gave GDC an opportunity to provide records that

could have clarified, corrected, or disputed information from other sources, including

interviews of staff and incarcerated persons. Although GDC eventually completed

production of documents responsive to our first subpoena, which was overseen by a

federal court, as of the time of publication of this report, GDC still has not completed

production of documents responsive to other requests, including a subsequent

subpoena issued in mid-2022 for records related to each of the facilities visited by

DOJ. Although GDC ultimately produced over 19,000 records, the process of obtaining

records and information from GDC was unnecessarily contentious and lengthy.

Throughout the investigation, we also sought and obtained information from state

entities other than GDC, including the Peace Officer Standards and Training Council

(POST), which trains and, in some cases, investigates GDC officers; the Georgia

Bureau of Investigation (GBI), which conducts some criminal investigations involving

the prisons; the State Board of Pardons and Paroles, which serves as a reporting entity

for sexual abuse allegations; and the Governor’s Office of Planning and Budget.

We also sought and obtained information from third-party sources. These included

emergency response companies, local coroners, medical providers, community-based

rape crisis centers, legal organizations and law firms representing people in GDC’s

custody or their survivors, and stakeholders such as community activists, currently and

formerly incarcerated people, their loved ones, and current and former employees of

GDC. Through these sources, we obtained thousands of pages of documents, some

of them official GDC documents obtained by third parties via open records requests.

We also conducted hundreds of interviews with stakeholders. We received more than

one thousand letters, emails, and other communications from people who are currently

incarcerated in Georgia prisons, as well as their loved ones and grassroots advocates.

We are grateful to the many members of the community who met with us and wrote to

us to share their experiences.

13

DEFICIENT CONDITIONS IDENTIFIED

GDC fails to provide incarcerated persons housed at the medium- and close-security

levels with the constitutionally required minimum of reasonable physical safety. GDC

also fails to provide incarcerated persons who are LGBTI reasonable protection from

sexual abuse. Failure to provide adequate staffing and supervision, to maintain basic

correctional operations, and to adequately deter, report, and investigate incidents has

created an environment of fear and complacency. Violence, including sexual assaults,

stabbings, beatings, and other brutal violence, is a systemic problem in prisons across

the state. Staffing levels at prisons housing people at the medium- and close-security

levels are inadequate to protect incarcerated people from harm. In many instances,

door locks are inoperable or manipulable. Gangs control housing units, directing

where other incarcerated people sleep and extorting incarcerated people and their

families for money. Contraband weapons, illicit drugs, and cellphones are

commonplace across the system. GDC therefore fails to protect incarcerated persons

from violence and harm, including sexual violence and harm. GDC’s practices also fail

to provide reasonable protection to LGBTI people, a vulnerable group in confinement

settings, from sexual abuse. Incarcerated persons, GDC staff, and the public are in

danger due to GDC’s failure to maintain a reasonable level of safety in its prisons.

A. The State of Georgia Fails to Reasonably Protect Incarcerated Persons

from Violence.

1. GDC allows frequent, pervasive violence in the prisons, resulting in

serious bodily harm and, in some cases, death.

The Eighth Amendment prohibits cruel and unusual punishment, which includes

gratuitous levels of violence at the hands of other incarcerated people.14 The

Constitution therefore imposes a duty on the State to take reasonable measures to

protect the people in its custody from harm.15 A reasonable response does not require

preventing every instance of harm, but it does require responding in an objectively

reasonable manner to known risks, such as by providing adequate supervision of the

14 U.S. Const. amend. VIII; Farmer v. Brennan, 511 U.S. 825, 833–34 (1994); Dickinson v. Cochran, 833

F. App’x 268, 271 (11th Cir. 2020); Q.F. v. Daniel, 768 F. App’x 935, 944 (11th Cir. 2019).

15 Farmer v. Brennan, 511 U.S. 825, 828, 832–33 (1994); Bowen v. Warden Baldwin State Prison, 826

F.3d 1312, 1319–20 (11th Cir. 2016); Dickinson v. Cochran, 833 F. App’x 268, 271 (11th Cir. 2020); Q.F.

v. Daniel, 768 F. App’x 935, 944 (11th Cir. 2019).

14

incarcerated population, proper

DEATH AT HANCOCK

classification, training of officers,

and sufficient searches to limit

On May 22, 2022, following evening chow,

dangerous contraband.16 The

an incarcerated person who identified as

State fails to meet its

LGBTI was beaten and stabbed to death

constitutional obligations when it

by multiple gang members inside a dorm

takes actions it knows “would be

at Hancock State Prison. The victim tried

insufficient to provide inmates with

to escape from the attackers by jumping

reasonable protection from

through t he s tair railings onto the floor

violence” and when there are

below, where the attackers then circled

other means available, but they

and continued to stab and curse at the

are disregarded.17

victim.

Abdicating its constitutional

Another incarcerated person was severely

obligations, Georgia has failed to

injured while attempting to stop the

protect people in its custody from

assault. A third incarcerated person

violence. The State continues to

stayed with the victim and attempted to

run its prisons as it has for years,

apply pressure to the victim’s wounds, an

without taking reasonable

act which he said he maintained while

measures to change course and

GDC staff were delayed in entering the

improve conditions. The

dorm.

consequences reflect systemic

breakdowns in basic correctional

According to an incarcerated person who

practices, including staffing and

witnessed the attack, the day before the

supervision, security systems,

homicide, the victim repeatedly asked to

contraband control, physical plant,

be moved because their life was in danger

classification, and housing. A loss

in their housing unit. The incarcerated

of control over the prisons has set

person who had attempted to stop the

in, with near-constant, life-

victim’s bleeding was transferred to

threatening violence functioning

another GDC prison the next day; he

as the norm.

claimed that he required protection there

because he was targeted by members of

According to GDC, from 2018

the same gang as the assailants.

through 2023, 142 people have

been killed in GDC prisons, on the

16 Dickinson, 833 F. App’x at 272–73; Caldwell v. Warden, FCI Talladega, 748 F.3d 1090, 1100–02 (11th

Cir. 2014); Bowen, 226 F.3d at 1320.

17 LaMarca v. Turner, 995 F.2d 1526, 1539 (11th Cir. 1993).

15

State’s watch. According to GDC

“SHAMEFUL”

mortality reports, in 2018, there were

In October 2020, at Georgia State Prison,

7 homicides systemwide; in 2019,

an incarcerated man was taken to the

that number jumped to 13

hospital by ambulance for a cut to his

homicides. Since then, there have

forehead and dark ligature marks around his

been well over 20 homicides in GDC

neck. He reported that his bunkmate had

prisons every year, with 28 in 2020,

tried to kill him by wrapping a sheet around

28 in 2021, 31 in 2022, and 35 in

his neck.

2023, according to GDC data. And

in the first five months of 2024, there

Less than five months later, an ambulance

were 18 confirmed or suspected

returned to GSP to pick up the s ame man.

homicides in GDC custody, based

This time, he had yellow and purple bruising

on GDC’s reported homicide totals

on the entire right side of his face, a

and other documentation.18 The rate

deformity indicating a possible jaw fracture,

of homicides in Georgia prisons

and multiple human bite marks all over his

significantly exceeds the national

body. The man w

as so malnourished that

average. The national average

every bone in his spine was bruised. He

homicide rate in state prisons across

reported that he had been kicked in the

the country for 2019 was 12 per

face, people had been stealing his food for

100,000 people. Georgia’s rate in

months, his bunkmate had been sexually

2019 was almost triple, at 34 per

assaulting and raping him, and nobody was

100,000 people, and the numbers of

helping him. He said that he had not eaten

homicides have increased

in five days.

precipitously since then.19

The emergency services provider wrote,

In addition to deaths due to violence

“This patient is scared. His body is wasting

in the prisons, other serious and life-

away and covered in signs of abuse. How

threatening incidents are

this has not been noticed by prison staff and

exponentially more frequent.

tended to before now is shameful.”

Assaults with weapons, fights,

sexual assaults, and other violent

incidents are common. In interviews at 16 of the 17 GDC prisons we visited in 2022

and 2023, incarcerated people consistently reported that they have witnessed life-

threatening violence, including stabbings, and that weapons are widespread in the

18 GDC’s numbers of verified and suspected homicides do not include an additional apparent homicide

death in early 2024. See Rob DiRienzo, Man Killed in Georgia Prison Laid There for Hours Before Guards

Came, Autopsy Suggests, FOX 5 ATLANTA, (June 10, 2024, 5:58 PM), https://perma.cc/YPW2-5T8V.

19 The Bureau of Justice Statistics latest report identifying national averages is current up to 2019.

16

prisons.20 While GDC incident reports document a longstanding pattern of serious

violence inside the prisons, we believe many violent incidents often go unreported

when they occur in unsupervised housing units or other areas with inadequate staff

supervision. In interviews with DOJ, incarcerated people explained that they do not

always report incidents because they do not expect staff to take any action in

response. Emails, letters, and calls to DOJ from incarcerated people and their

concerned loved ones also reported constant fear for physical safety, as well as

incidents of violence that our correspondents had personally experienced or witnessed.

Based on GDC’s records, the levels of reported incidents of violence within the GDC

system are consistently high. From January 2022 through April 2023, there were more

than 1,400 reported incidents of violence, including fights, assaults, hostage incidents,

and homicides, across the close-security prisons and most of the medium-security

prisons.21 Over this period, the overall incidence of violence gradually increased. Of

these incidents, 19.7% involved a weapon, 45.1% resulted in serious injury, and 30.5%

resulted in offsite medical treatment.

These numbers do not capture the full scope of violence within the system. First,

violent incidents are consistently underreported due to a lack of staff supervision and

other factors, causing some incidents never to be reported at all, as discussed later in

this Findings Report. Second, violent incidents are often mischaracterized using

inappropriate incident-type categories, resulting in under-counting of violent incidents

such as assaults and fights.

20 One smaller prison we visited, Walker State Prison, was a notable exception, with fewer incarcerated

people reporting they feared for their lives, and a much higher proportion of security staff positions filled.

Along with more robust programming, the more manageable staffing levels at Walker appeared to allow

the prison to operate with less violence and contraband, and more rehabilitative programming, than the

other prisons DOJ visited. There have been no reported homicides at Walker State Prison in the past

several years. We believe that Walker State Prison, along with a handful of other smaller facilities with

better staffing and programming, shows that larger-scale improvement is possible with an appropriate

strategy and sufficient resources.

21 For this analysis, the Department reviewed incident data produced from GDC from January 1, 2022 to

April 26, 2023, for Lee Arrendale State Prison, Augusta State Medical Prison, Autry State Prison, Baldwin

State Prison, Calhoun State Prison, Central State Prison, Coastal State Prison, Coffee State Prison, Dooly

State Prison, Georgia Diagnostic and Classification Prison, Georgia State Prison, Hancock State Prison,

Hays State Prison, Johnson State Prison, Macon State Prison, Phillips State Prison, Pulaski State Prison,

Rutledge State Prison, Smith State Prison, Telfair State Prison, Valdosta State Prison, Ware State Prison,

Wheeler State Prison, and Wilcox State Prison. These constitute 24 of the approximately 34 prisons in the

Georgia Department of Corrections housing incarcerated men or women at the close- and medium-

security levels.

17

of Violence among Incarcerated People

120

110

100

90

80

70

60

so —…… —–…… —.————.—–,.——Inc

The risk of life-threatening violence exists across GDC’s prisons, with noteworthy

spikes in violence at numerous facilities. Over the course of our investigation, no one

prison could be singled out as the locus of violence. In 2020, eight homicides occurred

at Macon State Prison, more than any other Georgia prison that year. In 2021, the

highest number of homicides at any one prison occurred at Smith State Prison. In

2022, Phillips State Prison had the most homicides, five; there were four homicides at

Macon that year. In 2023, seven incarcerated people and one CO were killed in

homicides at Smith State Prison.22 In June 2024, an incarcerated person at Smith

State Prison used a contraband gun to kill a food-service worker and then take his own

life. In March 2024, the Warden of Telfair State Prison was stabbed by an incarcerated

person during a disturbance that arose after a shakedown.23 Other prisons across the

system also have seen high levels of homicides and other serious incidents. For

22 Press Release, Georgia Dep’t of Corrections, Correctional Officer Killed ( Oct. 1, 2023),

https://perma.cc/Q3YM-BN5M.

23 See Carrie Teegardin & Danny Robbins, Prisoner Stabs Warden at Telfair State Prison, ATLANTA

JOURNAL-CONSTITUTION, Mar. 20, 2024, https://perma.cc/RF9S-ZPL9. GDC records confirm the basic

details.

18

example, in 2020, there was a major

A PLEA FOR HELP

riot at Ware State prison, in which

incarcerated persons obtained facility

In August 2022, staff at Pulaski State

keys, let scores of other incarcerated

Prison, a women’s prison, received a

persons out of their housing units,

call from outside of the prison, advising

including in restrictive housing units,

that an incarcerated person was being

held officers hostage and stabbed

stabbed in a dorm.

officers, set fires inside a housing unit

Staff was instructed to tour the dorm for

office and burned a GDC transport

safety and security, and report back.

cart, and broke into an office and

Staff reported that all was secure and

obtained officers’ weapons and

there were no problems to report, but

defensive gear. The riot resulted in

later they heard a faint cry for help

several hospital transports, including

coming from the window of the dorm.

four officers, one via helicopter life-

flight. Although different prisons have

When staff responded to the cell, they

been the most violent at different

found an incarcerated woman locked in

times, what has been consistent is that

her cell and slumped over the toilet.

the total number of homicide deaths

She had a gash on her head and was

systemwide continues to be extremely

bleeding profusely. She was holding

high.

her left side, crying, and saying she

could not breathe.

GDC blames gangs for the violence in

the prisons, along with the fact that

The woman had dark red marks across

many of the people in its custody have

her back and a bruise in the shape of a

been sentenced for violent crimes. But

footprint. She was wearing a medical

the modest increase in the proportion

gown and no underwear. She reported

of the men’s prison population

she was assaulted hours ago by more

incarcerated for violent crimes (not

than 10 people, that she was stomped

including sex offenders) – from

on, hit, and kicked. Incarcerated people

approximately 51% in 2016 to 56% in

forced her into the shower to wash the

2023 – does not explain the dramatic

blood off. She was transported to the

rise in violence in the prisons over the

hospital.

past five or so years. And although

some of the prisons with high numbers

of homicides are among the GDC prisons housing the highest numbers of validated

gang members, others that have also seen high numbers of homicides and other

serious violence have relatively low gang populations.

19

Moreover, national data and mortality data from comparable states also strongly

suggest that Georgia’s homicide rate has consistently been much higher than can be

explained by GDC’s population trends.

REPEAT ASSAULTS AT

Regardless, as the Supreme Court has

PHILLI

PS

explained, the State, after incarcerating

people who have demonstrated criminal

On August 3, 2020, an officer at

and, at times, violent conduct, and

Phillips State Prison was

“having stripped them of virtually every

conducting rounds in a housing

means of self-protection and foreclosed

unit when an incarcerated

their access to outside aid,” is “not free

person handed him a note

to let the state of nature take its

stating that an incarcerated

course.”24

person in another cell had been

held hostage for days, was

Sexual violence also is a systemic issue

yelling for help, and might be

across Georgia prisons. GDC reported

injured. In May 2023, DOJ

635 sexual-abuse allegations in 2022

interviewed the victim, who

(the most recent year for which a

reported that he had been held

systemwide PREA report is available),

and tortured for almost four

639 in 2021, 702 in 2020, and 653 in

days, he had been stabbed from

2019.25 These numbers likely fail to

behind and his eye was pierced,

capture the scope of the harm, as

and he suffered a traumatic

incarcerated people explained that

brain injury.

sexual assaults are not reported, either

for fear of retaliation from those who

Almost exactly a year later, on

assaulted them, or because incarcerated

August 12, 2021, the same

people believe GDC will fail to address

assailant assaulted another

their complaints.

incarcerated person at the same

prison; the victim of the second

In some instances, victims accessing

assault required outside medical

medical attention shed light on the

treatment at a hospital.

severity of the problem:

•

At Pulaski State Prison, in February 2022, an incarcerated woman was

transported to the hospital for vaginal bleeding and stomach pain. She alleged

that her roommate sexually assaulted her with a hot sauce bottle and that she

24 Farmer v. Brennan, 511 U.S. 825, 833 (1994).

25 These allegations include sexual abuse of incarcerated people by other incarcerated people and by

GDC staff.

20

yelled for an officer, but no one came to the cell to help. She reported

continuing to suffer flashbacks to the assault.

•

At Smith State Prison, in May 2020, GDC staff informed emergency services

responders that an incarcerated person had been tied up, beaten, and

waterboarded by his cellmate. The cellmate also inserted multiple bars of soap

into the victim’s rectum. One bar of soap, covered in stool and blood, had

already fallen out. The victim suffered multiple contusions to his face and chest

and was bleeding heavily from his nose and mouth. He had ligature marks on

his neck and still had makeshift binding around his wrist. He was transported to

a local hospital; while he was being moved to an emergency-room bed, two

more bars of soap fell out of his rectum. The hospital found that most of his

upper teeth had been broken during the assault. One hundred-fifty milliliters of

blood was suctioned from his airway.

From within GDC prisons, incarcerated people frequently use contraband cellphones to

record assaults or to contact family and friends of incarcerated people. Incarcerated

persons and their loved ones report that other incarcerated people have been

assaulted or threatened with violence in efforts to extort money from family or loved

ones outside the prisons, and GDC’s own homicide investigations have uncovered

evidence of extortion. Desperate, members of the community have reached out to

GDC, calling to get their loved one to safety, but the problem persists. Over the past

several years, a steady stream of contraband cellphone videos and photographs

appearing to show assaults, incarcerated people with injuries, weapons, and

incarcerated people who seem to be under the influence of illicit drugs – all while inside

Georgia prisons – have been shared to social media, the press, and community

stakeholder groups, painting a picture of lawlessness and disorder inside GDC prisons.

Even when GDC had ample notice that DOJ would be visiting their prisons, several

serious incidents occurred during, immediately before, or in the immediate aftermath of

our site visits, including the following:

•

Shortly before DOJ visited Wilcox State Prison for a site visit in June 2023, a

video shot on a contraband cellphone circulated on social media, appearing to

show an incarcerated person assaulting another incarcerated person outdoors

on a prison walkway, while an officer watched. GDC records confirm that

multiple officers, including those in supervisory positions, brought an

incarcerated person who served as a “warden’s orderly” to the victim’s housing

unit to help move the victim to another part of the prison. The victim already

had been assaulted by another incarcerated person inside his housing unit.

Prison staff then allowed the assailant to strike the victim and to use a cart to

drag the victim, who was lying limp, along an outdoor walkway, with one bare

21

foot dragging on the pavement. Two Wilcox COs were terminated from GDC

employment shortly thereafter.

•

DOJ conducted a two-day site visit at Rogers State Prison in March 2023.

Shortly after DOJ left the facility on the first day, in the early evening, an

incarcerated person was assaulted by another incarcerated person, requiring

outside medical attention at a hospital. Between that night and the following

morning, there was another violent incident in a different housing unit, also

resulting in serious injuries. The following day, DOJ interviewed two

incarcerated people who said the second incident occurred in their housing unit,

that it was a gang-related fight involving multiple knives, and that at least one

individual was stabbed and taken to the hospital.

•

On March 27, 2023, Smith State Prison went into lockdown immediately before

a DOJ site inspection. GDC imposed the lockdown because of a fight with

weapons early that morning following the serving of a Ramadan breakfast

inside the D-2 dorm. Seven individuals required hospitalization, two by air

evacuation. The melee allegedly began when members of various gangs

retaliated against an incarcerated person self-identifying as a Muslim for a

previous incident while there were no officers in the dorm. The Incident

Response Team took about an hour to respond. Several incarcerated persons

were seriously injured, requiring two medical airlifts and five ambulance

transports to hospitals. These incidents occurred less than two months after

the warden of this facility was arrested for his alleged participation in gang

contraband smuggling.

•

Shortly after DOJ interviewed several incarcerated people on-site at Coastal

State Prison in the fall of 2022, one of the people we interviewed, a transgender

woman with a diagnosis of gender dysphoria and a history of mental health

issues, died of an apparent suicide.

•

On June 27, 2022, the second day of DOJ’s site visit to Ware State Prison, an

incarcerated person there was blindfolded, tied up, beaten, and burned by other

incarcerated people. He went to the medical unit where he was diagnosed with

first- and second-degree burns. DOJ interviewed him the next day and

observed burns on his body and injuries to his face. The victim said that he

reported the assault to staff, but they did nothing. After the interview, DOJ

informed GDC that the victim likely needed mental health and medical

attention. The victim subsequently was moved to medical housing.

•

Shortly after DOJ’s visit to Ware, we learned that another man we had

interviewed there had died days later. On June 29, 2022, in an interview at

22

Ware State Prison, an incarcerated person reported that he had gone almost a

year without a mattress. That week, he was blocked from going to the

bathroom by another incarcerated person, who chased him with a broom and a

rock. He defecated in his pants. He described experiencing post-traumatic

stress disorder, said that GDC was worse than his time seeing combat in the

military, and explained that drugs are easy to acquire in the facility. Four days

after the interview, he died from a drug overdose. On July 3, 2022,

incarcerated persons at Ware found him slumped over a second-floor cell block

railing. He was left there for several hours because there were no officers in

the control center and staff failed to come to the building. Video shot by

incarcerated people on a contraband cellphone showed this man’s apparently

unconscious body draped over an upper-tier railing for an extended period of

time. In the video, the individual holding the camera says, “we have an inmate

here that is dead . . . for the past two-and-a-half hours. It’s crazy. This is

crazy.” The victim’s cause of death was acute methamphetamine toxicity.

GDC likewise failed to protect individuals interviewed by DOJ from violence in the

months and years after facilitating those interviews. In late May 2024, an incarcerated

man whom DOJ interviewed at Macon State Prison in early 2023 reportedly died by

homicide at Augusta State Medical Prison, where he had been transferred. The victim

was attacked on multiple occasions in the years prior to his death. Two other

incarcerated people and a GDC CO have been criminally charged.

2. GDC’s grossly inadequate staffing leaves incarcerated persons

unsupervised and hampers staff’s ability to respond to violence.

Incarcerated people in GDC’s custody are at substantial risk of serious harm due to

severe understaffing in Georgia prisons. In the past several years, staffing in GDC

prisons has been too low to provide reasonable supervision. Vacancies and turnover

are high, especially among security staff who are directly responsible for supervising

incarcerated persons. GDC has failed to improve its dire staffing problems.

Maintaining adequate staffing levels and ensuring supervision of the population are

critical components of a safe and secure prison facility, particularly protection from

harm including from violence and sexual abuse. Failure to maintain sufficient staff and

supervision may show deliberate indifference to substantial harm in prisons, in violation

of the Eighth Amendment.26

26 See Marbury v. Warden, 936 F.3d 1227, 1235 (11th Cir. 2019) (explaining that deliberate indifference

may include evidence of “pervasive staffing and logistical issues rendering prison officials unable to

address near-constant violence, tensions between different subsets of a prison population, and unique

risks posed by individual prisoners or groups of prisoners due to characteristics like mental illness”);

Dickinson v. Cochran, 833 F. App’x 268, 272–73 (11th Cir. 2020); Q.F. v. Daniel, 768 F. App’x 935, 946

23

GDC leadership has long presided over a system with severe staffing shortages, with

systemwide CO vacancy rates over 50% since mid-2021 – too low to operate

reasonably safe and functional facilities.27 Beginning in the mid-2010’s, a downward

trend in staffing numbers already had begun. From 2014 to 2018, GDC’s annual

average CO vacancy rate climbed from almost 11% to over 18%. Between 2018 and

2023, GDC staffing levels fell precipitously, reaching a systemwide CO vacancy rate of

60% in April 2023, with over 2,800 vacant officer positions. GDC claims that, by the

end of 2023, they were hiring more security staff than they lost and were no longer

netting negative hiring numbers. Nevertheless, GDC’s systemwide correctional officer

vacancy rate remains above 50%. Indeed, as of the end of 2023, GDC still had over

2,800 unfilled CO positions.28

Moreover, GDC’s most violent prisons have

GDC is operating most

of its close- and

medium-security prisons

with more officer posts

vacant than filled.

much higher staff vacancy rates than the

systemwide average. In April 2023, the vacancy

rate was over 60% at 20 medium- and close-

security prisons; twelve of these prisons had

vacancy rates above 70%. By the end of 2023,

CO vacancy rates remained in the same range

at GDC’s most dangerous prisons. In

December 2023, the vacancy rate was over 60% at 18 medium- and close-security

prisons; ten of these prisons had vacancy rates above 70%. Most of the GDC facilities

with much lower CO vacancy rates were less violent, lower-security facilities such as

transitional centers.

(11th Cir. 2019). See also, e.g., Alberti v. Klevenhagen, 790 F.2d 1220, 1227–28 (5th Cir. 1986)

(upholding district court’s finding that inadequate staffing and supervision, among other factors, led to a

pattern of constitutional violations); Van Riper v. Wexford Health Sources, Inc., 67 F. App’x 501, 505 (10th

Cir. 2003) (“When prison officials create policies that lead to dangerous levels of understaffing and,

consequently, inmate-on-inmate violence, [there is a violation of the Eighth Amendment.]”).

27 Our analysis of GDC’s staffing inadequacies is based on our review of GDC records, interviews with

GDC facility staff and leadership officials, and our observations in the facilities. For the most part, our

assessment of staffing vacancies is based on GDC’s existing allotted positions and current staffing plans.

Other than facility staffing plans, which GDC produced for numerous facilities, we requested, and GDC has

not produced, any staffing analyses that GDC may have conducted. Such a comprehensive staffing study

and review needs to be conducted as part of any remedy for the State’s staffing and retention deficiencies.

28 Although the COVID-19 pandemic exacerbated GDC’s hiring and retention problems, it did not create

them. GDC’s severe understaffing predates the pandemic. By February 2020, three close-security men’s

prisons had CO vacancy rates near or over 50%. Turnover, likewise, already was an issue; in January

2020, GDC hired 146 COs and lost 175; in February 2020, GDC hired 134 COs and lost 131. During this

pre-COVID period, violence levels in GDC prisons began to rise significantly. For example, in 2019, the

number of homicides in GDC prisons jumped to 13; the number had been in the single digits for the

previous several years.

24

The reality of these high vacancy

DEATH AT CALHOUN

rates is that GDC is operating

In February 2023, an incarcerated person

most of its close- and medium-

was found dead in his restrictive-housing cell

security prisons with more officer

at Calhoun State Prison, leaning against the

posts vacant than f illed, resulting

door and wrapped in a mattress padding.

in inadequate security and

About thirty minutes after a GDC officer

supervision. In December 2023,

noticed that the man had not moved for

at eleven close- and medium-

hours, emergency responders were called.

security GDC prisons, 100 or

more officer positions per facility

They arrived at the prison at 1:04 p.m., but

remained vacant. In f act,

due to delays waiting for staff to open the

between October 2022 and the

prison gates, they were not inside the prison

end of 2023, more than 15 state

until 1:11 p.m. They confirmed the death and

prisons housing individuals at the

reported that the coroner was needed. Upon

medium- and close-security levels

arriving, the coroner also had to wait at the

saw a net loss in filled CO

prison gate, as no one was there to let him in.

positions, while several others

saw increases only in the single

The coroner reported that the incarcerated

digits. In interviews with DOJ in

person’s cell was a mess: the mattress torn

late 2023, staff at large men’s

up on the floor, food trays strewn about. The

prisons housing incarcerated

body was stiff; the coroner believed the

people at the close-security level

person had been dead for seven to eight

reported that high CO vacancy

hours before he was found. Speaking to

rates over 60%, as well as

emergency dispatch later, the coroner said

significant vacancies among

there was “some shit that ain’t right about this

supervisory security staff,

inmate.”

persisted. GDC’s purported

Prior to this person’s death, no one had

attempts to address its

entered his cell for two days. The flap in the

increasingly dire staffing

door had been locked shut earlier that week.

shortages remain far short of

Incarcerated peopl

e reported to DOJ that the

addressing the problem.

deceased person had thrown water out of his

Despite modest salary increases

cell flap and that staff had shut off the water

and job advertising, GDC has not

supply to his room, closed the flap, and did

taken reasonable, proportionate

not deliver meals to him. His cause of death

steps to ensure pr

ison s taffing

was dehydration with renal failure.

that is adequate to protect

incarcerated persons from harm.

Following a recent salary increase, COs currently make starting salaries in the $40,000

– $44,000 per year range, depending on the security level of the facility at which they

25

work. Notably, GDC’s Human Resources Director acknowledged that GDC still “lag[s]

behind in the salary market,” so pay remains “a factor.” Commissioner Oliver also

acknowledged that in addition to compensation, ensuring that the work is a “calling”

and that officers have “passion” for their jobs are important to retention. In interviews

with DOJ, GDC officials also said they hope that a relatively new contract with a

consulting firm to help GDC become “certified as a great place to work by 2027” will

increase officer retention through staff training and workshops. However, morale and

working conditions for GDC security staff appear to remain a challenge. For example,

in employee morale surveys conducted at several facilities in 2023, employees cited as

the “worst” aspects of their jobs or as the “biggest challenges” facing GDC, factors

including “retaining quality staff,” “staff morale,” “work environment,” and the “safety

and security of facilities.”

With a systemwide CO vacancy rate over 50%, GDC cannot, and does not, staff the

most critical posts or conduct other basic correctional operations in its prisons.

According to GDC policy, for a prison to maintain normal operations, allotted posts at

the Priority 1, 2, and 3 levels must be filled; of these, Priority 1 posts are considered

critical. For example, at the prisons that house incarcerated persons at the medium-

and close-security levels, it is generally required that each housing unit be staffed by

two or more officers in 24/7 Priority 1 (or otherwise designated as mandatory) posts,

with additional Priority 1 posts assigned around the facility, including those stationed at

the front entrance and patrolling the perimeter. According to GDC, all incarcerated

persons classified as close security – over 11,000 incarcerated people, about 23% of

GDC’s total population – always require supervision by a CO.

Yet GDC leadership and facility staff acknowledged, and our review of staffing

documents confirms, that, at several prisons, Priority 1 posts are consistently and

frequently vacant, leaving officers unable to conduct required rounds and other duties,

let alone directly supervise the population. Facility staffing records document

deviations from mandatory staffing requirements, acknowledging that, due to CO

staffing shortages, the minimum requirement of CO coverage cannot be met, and that

sergeants and unit managers need to assist with basic housing unit coverage. In

practice, however, GDC does not have enough staff, even including supervisory staff,

to cover its Priority 1 posts at many of the prisons we visited. GDC documents and our

interviews with prison staff illustrate the staffing triage that has become common across

the system. Staff at several GDC prisons have adopted a practice of assigning one CO

to single-handedly supervise two buildings at a time, each comprising two or more

housing units and hundreds of incarcerated people, for an entire 12-hour shift. For

example:

26

•

At a large close-security men’s prison known for gang problems and violence, a

sampling of staffing rosters from day and night, weekday, and weekend shifts in

mid-2023 confirmed that the prison is consistently staffed with well under half

the security staff needed to ensure coverage of Priority 1 posts. On every shift

roster we reviewed, there was at least one, and sometimes up to four, officers

assigned to two buildings at a time; in other words, each of those officers was

single-handedly responsible for nearly 400 beds. Although for a period of time

GDC had assigned additional Special Operations officers to assist with

coverage of this prison, those additional officers were reassigned away from the

facility, with no plans to replace them. The Regional Director responsible for

this facility acknowledged that, in practice, the staff assigned to multiple posts

are required to switch posts every 30 minutes to check on incarcerated persons

in multiple buildings, leaving units and entire buildings unsupervised during

those times.

•

At another large men’s prison, a sampling of staffing rosters from 2023 showed

that facility leadership consistently assigned officers to cover multiple housing

units on the same shift, and that on some shifts supervisory security staff were

assigned to cover officer posts in housing units. A medical employee who

worked at the facility reported there have been times when only two officers

were available to cover the entire compound. At times, this employee reported,

the perimeter officer would need to vacate the perimeter post to cover security

posts inside the facility.

•

A shift supervisor at a large medium-security men’s prison, whom we

interviewed in mid-2023, reported that in a given month, there is unlikely to be a

single day on which each building in the prison is covered by at least one

officer.

GDC’s investigations make clear that staffing shortages place security staff in an

untenable position and have contributed to homicides and other serious assaults. For

example, an investigation of a homicide at a GDC men’s prison in 2021 found that no

staff checks had been done after 9:20 p.m. the night before the death; the body was

found the next morning around 9:00 a.m. In 2022, at a close-security men’s prison, an

incarcerated man was killed after being assaulted while handcuffed. The investigation

found that the officer on duty was single-handedly supervising a control center as well

as both sides of the housing unit building where the homicide took place.

Other incidents reveal that when security staff is stretched this thin, incarcerated

people are at greater risk of harm. For example, on a weekend day shift in August

2023, at a large men’s prison, one officer was assigned to three separate buildings due

to staffing shortages. In the late afternoon, this officer had to leave the prison to escort

27

a stabbing victim from another building to the hospital; the victim had been stabbed 32

times in his back, head, and stomach. The next day, the same officer was again

assigned to three separate buildings due to staffing shortages. The staff logbook from

the building where the stabbing took place contains no entry of the stabbing, indeed,

there are no entries at all after 8:54 a.m. on the day of the stabbing. Staff logbooks

indicate that, the very next day, no officer was assigned to that building for the second

shift, again due to staffing shortages. For six of the next eight days, the building’s

logbook has no entries at all. Despite a stabbing requiring hospital care, GDC failed to

improve staffing in the affected housing units the very next day, and continued the

status quo of little-to-no supervision in the affected units over the weeks following that

incident. This account of GDC’s continued inadequate supervision and violence

among the population is illustrative of GDC’s systemwide staffing problems.

During DOJ’s 17 facility site inspections, our experts observed GDC’s short staffing in

person. While our teams were accompanied by several Special Operations officers

brought in to facilitate our visits, generally a smaller number of facility-based staff were

present. It was not uncommon on our tours for GDC to temporarily assign dozens of

Special Operations staff to the facility, to allow our group to tour the facility and to

facilitate incarcerated people’s movement to participate in interviews with DOJ. GDC

insisted on setting all of DOJ’s site visits several weeks or months in advance to

facilitate preparations, and repeatedly informed us that our group could not split up

while on-site, due to the security challenges multiple escorts would pose. As a result,

GDC did not permit DOJ to tour spontaneously and observe normal operations in the

prisons. However, we still observed evidence of inadequate staff supervision. For

example, in most of the 17 prisons we toured, our experts repeatedly noted that control

centers in housing units appeared to be unmanned and found little evidence that they

were consistently occupied (e.g., officers’ personal belongings, computer equipment

such as a mouse or working monitor).

Similarly, GDC records confirmed that, day-to-day, across the close- and medium-

security prisons, staffing shortages are a constant challenge for the officers who are

working. The security staff tasked with running a prison with insufficient backup are

forced to cut corners on important prison functions including rounds and wellness

checks, as well as proper documentation and recordkeeping. For example, in a

sampling of internal GDC audits from 2023, in 12 out of 13 prison audits, staff failed to

properly document required 30-minute cell checks in segregated housing units, with

auditors noting that there were lengthy periods of time with no documented checks, or

evidence that the checks had been documented before or after the fact, instead of

28

contemporaneously.29 One officer reported that staff often are unable to conduct the

searches mandated by policy. Without adequate supervision, incarcerated people are

at greater risk of violence and other harm due to unchecked gang activity, assaults,

extortion, and access to weapons and drugs.

Not only does GDC fail to adequately staff its prisons, it also fails to take reasonable

steps to mitigate its staffing shortages. One way to attempt to mitigate the danger

posed by housing units with minimal or infrequent officer presence on the ground is to

monitor video in the housing units. Yet at multiple facilities, security and leadership

staff reported to us that surveillance video in the housing units is not monitored in the

housing unit control centers or from central control. While the warden generally has

access to housing-unit surveillance video, the shift supervisor and lower-level security

staff do not. The result of these practices is that nobody is supervising the population

in real time.

GDC’s consistent failure to ensure that even minimum staffing levels are met leads to

unsafe prisons. With housing units left unsupervised for sustained periods of time,

incarcerated persons can engage in illicit activities, including exchanging contraband,

abusing drugs, making homemade weapons, fetching contraband via drone drops, and

engaging in violent assaults. Violent incidents are more likely to occur. Gangs and

other threat groups tend to step in to fill the void in leadership, telling people where

they can or can’t sleep and exerting control over prison life. When security staff are not

present to report incidents, perpetrators may not be held accountable and can continue

to cause harm to others. Appropriate follow-up, such as reassigning someone to

another housing unit for protection or reclassifying someone who perpetrated an

assault, may not occur.

GDC’s failure to ensure staff presence, supervision, and enforcement of rules and

policy in the prison housing areas contributes to an unsafe environment. Efforts to

enforce prison rules and ensure incarcerated people are where they are supposed to

be also falter without adequate staff. In hundreds of interviews, incarcerated persons

reported to DOJ that officers and other staff are in the housing units infrequently and

that housing units and entire buildings often are completely unsupervised. This results

in the proliferation of contraband and violence, as well as other rule violations that

impede orderly and safe correctional operations. For example, incarcerated persons

and staff consistently reported that it is common for incarcerated persons to sleep in

beds other than those to which they are assigned, often because other incarcerated

persons who have more power in the housing units tell people where to sleep, and

29 In an internal proposal identifying areas of concern, a GDC official who oversees compliance matters

noted that GDC is failing to accomplish appropriate internal training and highlighted short-staffing

challenges in the unit that conducts these facility audits.

29

officers do not notice or fail to correct the relocation. This practice illustrates how GDC

staff are not in control of the population.

In the event of an emergency, without adequate staffing, the ability to respond in a

timely manner is severely hindered. If an assault or other violent or medically urgent

incident occurs while staff are not present, the delivery of critical medical treatment to

the injured person or persons may be significantly delayed. For example, in mid-2023,

an incarcerated man at a large men’s prison died after he was badly injured in a fight

with another incarcerated person in a housing unit. A supervisory member of the

medical staff recounted that a nurse who responded to the incident was “distraught”

after the man died, because, in the immediate aftermath of the assault, medical

personnel were not permitted to enter the housing unit due to insufficient security staff

to escort them.

We also received reports of concerned loved ones calling the prison to report an

ongoing or recent incident of life-threatening or other serious violence occurring in

unsupervised areas. In these cases, other incarcerated people have used contraband

cellphones to call loved ones, who in turn call the facility to report the assault. GDC

incident reports likewise document incidents where staff was alerted to an emergency

by a call from outside the prison.

GDC records and EMS reports demonstrate how understaffing causes avoidable

delays in providing medical care in emergencies. For example, GDC records on four

deaths of incarcerated persons in 2021 describe bodies that were discovered by staff

after the onset of rigor mortis, indicating that hours had likely passed since the

individual had died. In interviews with DOJ, multiple EMS directors identified delays in

reaching patients in the prisons, which were apparently due to GDC staffing

inadequacies. For example, one EMS director said that security staffing shortages

appear to affect the ability of EMS teams to reach incarcerated people in need of

emergency medical care. This EMS director estimated that EMS teams are delayed an

average of 30 minutes during emergency responses to a GDC prison, waiting for

security staff to open the three gates necessary to access the prison’s medical

department. The EMS director also said that overnight staffing appears to be a

significant issue, noting that there have been instances where it appeared that an

emergency had occurred during the night shift, but prison staff had not requested EMS

until the next day. The EMS director also described difficulties in obtaining security

escorts for EMS hospital transports due to security staff shortages.

Numerous incidents from across the system highlight how understaffing has

contributed to delays in necessary medical care reaching incarcerated persons who

have been harmed in violent incidents. For example:

30

•

In June 2022, emergency services responded to Coastal State Prison for an

unresponsive person. When they arrived, after some delay, they were taken to

a cell where an incarcerated man lay dead on the ground. The body had rigor

mortis, and was “pale and cool to the touch.” GDC staff informed emergency

responders that the man was in rigor when they got to him and that they found

a syringe near his bed. The cause of death was an overdose.

•

On August 20, 2021, emergency services responded to Georgia State Prison

for a stab wound. An incarcerated person reported that he was hog tied all

night, stabbed, and then released in the morning after being tied up for over

eight hours. Emergency responders noted indentations on the incarcerated

person’s arms and legs where he was tied. He was airlifted to a hospital.

•

On December 8, 2020, emergency services responded to Georgia State Prison

for an incarcerated person suffering burns to 90% or more of his body. The

incarcerated person reported that he was using the phone, laid it down onto the

metal flap of his door, and then it caught fire. The fire ignited his clothes and

then burned his body. Emergency responders observed burns on his chest,

abdomen, back, armpits, left hand, groin, penis, testicles, buttocks, legs, and

feet. The man was in extreme pain. Staff reported that the incident was

suspected to have happened around 4:00 p.m. to 5:00 p.m., but the

incarcerated person was not brought to the medical unit until around 10:24

p.m., just prior to calling emergency services. Transport to the hospital was

delayed because prison security staff did not have an officer ready to go. The

incarcerated person was eventually airlifted to a hospital.

•

An incarcerated person was stabbed multiple times on May 23, 2022, at Ware

State Prison. There was no security staff in the dorm, so other incarcerated

people beat on the window to draw the attention of staff. It took half an hour for

someone to respond. The victim was taken to the hospital, where he was

diagnosed with a collapsed lung from a stab wound. After five days in the

hospital, he returned to Ware and was locked down in isolation. He was never

interviewed about the incident.

Given these delays, it is commonplace for incarcerated people to tend to their own

injuries and medical needs after a fight or an assault. We interviewed incarcerated

people who reported cleaning and dressing their own or others’ wounds in

unsupervised prison areas, using things like toothpaste, coffee grounds, dirt, and

makeshift bandages to dress open wounds; medical records corroborated some of

these accounts. For example, in an incident report from a large close-security men’s

prison in August 2023, an officer reported that he was approached in an outdoor area

of the prison in the middle of the night shift, by three incarcerated men wheeling

31

another incarcerated person on a cart to the medical unit. The officer reported that

after calling 911 he escorted the victim to medical, where his homemade wound

dressings were removed to expose large cuts on his stomach and upper arm. The

victim was not alert and intermittently losing consciousness. The officer also noted that

the incarcerated people likely exited their housing unit through a fire-exit door and cut a

large hole in fencing to reach the medical unit.

Understaffing causes other systemic deficiencies as well. Reporting and

recordkeeping is severely hindered by the lack of staff. For example, security staff

from different facilities reported that in some cases an officer covering two separate

buildings carries a logbook from building to building to log during their shift. At another

facility, security staff call logbook entries to central control, where they are logged by

the officer on duty there. Our review of prison records confirmed that in many

instances logbooks are labeled for more than one housing building. Failing to maintain

a logbook at a dedicated security post is not sound correctional practice, and

jeopardizes prison safety and control. The purpose of a logbook is for staff to record

what is occurring on the security post. The practice of carrying a logbook from one

building location to another can result in information not being recorded for the post.

Security staff arriving at a post, on rounds or otherwise, may assume there is no

logbook, or may not obtain critical information from the logbook. Similarly, if one

logbook is maintained in central control, and entries must be called in, correctional staff

will have limited access to the logbook, both for purposes of entering information and

reviewing entries from prior shifts. Additionally, moving logbooks around the prison as

a matter of course can result in the logbook being damaged, misplaced, or taken by

incarcerated persons.

Understaffing also can lead to infrequent security and wellness checks and failure to

properly document security rounds and other central functions of correctional security

staff. GDC’s internal facility audits confirm serious failures in security-related

documentation and recordkeeping in multiple operational components that directly

affect safety. For example, the audits found evidence that supervisors had cleared

counts despite discrepancies, and that count packets, count slips, and other

documentation related to counts were inaccurate. The 2023 facility audits also

identified delays in submitting incident reports; inaccuracies and discrepancies in

documentation related to contraband control; incomplete documentation and logs for

visitor records and facility entry; inconsistent implementation of required checks and

documentation thereof in segregated housing areas; failure to maintain appropriate

lists and other records of chemicals, tools, and other materials that could be used for

illicit purposes; and inadequate inspection procedures, resulting in irregular

performance of required tests.

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The audits also indicate that wellness checks are not conducted as required by policy.

For example, 2023 internal compliance audits of operations in segregated housing

units in several GDC prisons found evidence of improper documentation of thirty-

minute checks in administrative segregation: instead of documenting thirty-minute

checks next to each cell door when they occur as required for the safety of individuals

in these units, officers likely had back-filled the check logs at the end of a shift.

Adequate security staffing and supervision are essential to a minimally safe and secure

prison. GDC’s failure to ensure adequate staffing in the prisons contributes to harm

from violence and to unsafe facilities across the state.

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physically secure, incarcerated people, as well as employees and visitors, are at an

3. GDC prisons are unsafe due to aging and inadequately maintained

facilities and failure to ensure adequate lock, tool, and key controls.

Working locks, systems to monitor the use of tools and keys, and adequate preventive

maintenance are essential components of prison security. If a prison facility is not

unacceptable risk of harm due to

uncontrolled movement. Additionally,

damage to facility hardware and

infrastructure poses risks to incarcerated

persons’ physical safety, as furniture and

fixtures can be dismantled to make

weapons, holes in ceilings and walls can

be used to gain access to unauthorized

areas or to hide contraband, and

dilapidated and unsanitary conditions can

lead to internal tension. GDC fails to

maintain its prisons in reasonably safe and

secure condition, placing incarcerated

people and others inside and outside the

facilities at unacceptable risk.

GDC’s internal facility audits, as well as

information DOJ obtained from facility site

inspections and interviews with staff and

incarcerated people, establish that GDC

does not take the steps necessary to

maintain secure prisons, including timely

preventive and corrective maintenance.

Problems with lock functionality are

documented in GDC’s internal audits of

multiple prisons. Leadership has

acknowledged that aging facilities raise

challenges across the system, with the

average GDC prison over 30 years old

and reaching “end of life,” according to a

recent public presentation by the

Commissioner.

34

A hole in the wall at a men’s prison in 2023.

Damaged shower door in a housing unit at a GDC

men’s prison in 2023.

Staff from several prisons reported that incarcerated people are able to manipulate

cell-door locks, damage door hinges, and otherwise tamper with security hardware and

infrastructure; incarcerated people then are able to exit cells unauthorized, and even

exit housing units to go to different areas of the prison at all hours. One warden told

DOJ that door locks in his large facility are frequently “popped”; a captain at the same

facility said that incarcerated people pop the locks of their cells “all the time,” and

sometimes of the housing

units. According to staff at

another prison, doors in the

medical unit, including doors

that lead to the administrative

offices, have not had working

locks for at least 17 years, and

incarcerated people walk into

the staff breakroom and steal

food from the refrigerator on a

regular basis. During site

visits, DOJ experts repeatedly

observed malfunctioning lock

indicator lights, padlocked

doors, and improperly secured

areas.

Frequently, GDC fails to

promptly fix things that break

in its facilities – even when the

thing that is broken is as

central to prison operations as

a lock or key. A 2023 GDC

facility audit found that staff

failed to submit maintenance

requests for broken keys.

Staff at the same prison

explained in an interview with

DOJ that the officer designated

to perform lock-and-key duties

is frequently pulled from that

assignment to cover security posts, and therefore is unable to maintain the lock-and­

key system at the prison. Staff from GDC prisons said that getting broken locks fixed is

Engaged padlocks on restrictive housing unit cell doors in a

close- security GDC prison in 2022. An officer at this prison later

told DOJ that padlocks are not used on cell doors at this prison.

35

a perennial challenge due to issues including short staffing, not having a locksmith on

staff at the prison, or challenges obtaining parts to fix old locks.

Exposed wiring and

damaged fixtures in areas

accessible to incarcerated

persons at a GDC prison

in 2022.

Our observations during facility site inspections, as well as information received from

staff interviews, confirm that GDC sometimes inappropriately uses padlocks on cell

doors, apparently due to broken primary locks. Using padlocks on cell doors is a

violation of national correctional standards, and GDC’s fire safety inspections have

identified doing so as a violation. This practice exposes incarcerated people to an

unacceptable risk of harm in the event of a fire or other emergency, because of the

additional time it would take to evacuate.30 GDC’s staffing shortages and inoperative

fire safety systems (e.g., fire detectors and alarms) further exacerbate that risk. When

30 Inadequate fire safety systems expose incarcerated persons to unacceptable risk of harm in fire-related

emergencies. While DOJ’s investigation focused on violence, we consider all fires, whether or not

intentionally set by incarcerated persons, to present serious life safety risks in GDC prisons. We observed

and staff reported serious problems with prison fire safety systems. In some prisons, entire systems or

most alarms are nonoperational due to GDC’s failure to fix them. For prisons or areas within prisons with

inoperable fire alarm systems, prison staff is required to conduct fire watch rounds every 30 minutes; our

review of logbooks and audits confirmed these rounds do not always occur with the required frequency. In

our expert’s view, the GDC official tasked with managing the system’s fire safety program does not have

sufficient authority to make necessary improvements to fire systems in the prisons, exposing incarcerated

persons to an unreasonable risk of harm.

36

asked about padlock use, staff responses were inconsistent.

Some staff acknowledged that padlocks are sometimes used

on cell doors when the primary lock is malfunctioning.

However, other staff reported that padlocks are not used on

cell doors; in some cases, this claim contradicted our own

observations while touring the prisons at which those staff

members worked. For example, during one prison site visit,

DOJ observed and photographed padlocks on doors in three

occupied housing units, where an officer we later interviewed

said padlocks were not used. DOJ observed padlocks on

doors in other housing units and prisons throughout our

investigative site visits in 2022 and 2023.

Incarcerated people interviewed at multiple prisons likewise

reported issues with door security in housing units. These

issues include cell-door locks that are manipulated to “pop

out” of cells, doors that are jammed to stay open or closed,

and other tampering with basic door-locking mechanisms.

Other incarcerated persons reported that staff leave doors

and fence gates unlocked, allowing free movement within

housing units – and sometimes out of units and into

unauthorized areas of the prison compound. Non-working

door control panels pose a significant safety risk, as doors

must be unlocked manually and there are often no staff

present in the housing units.

GDC acknowledges that it has problems maintaining secure

door locks, and informed DOJ during several facility site

inspections that various housing units were temporarily

closed due to a rolling “lock hardening project” in the

facilities. GDC leadership staff also informed us of lock

upgrades that are underway.

However, such projects are not sufficient to address GDC’s

entrenched security problems. Locks likely will remain an

issue, even after being “hardened” or replaced, because

GDC does not have sufficient security staff to supervise

incarcerated persons and prevent further damage to and

manipulation of door locks. Additionally, GDC does not have

sufficient security and maintenance staff to maintain

Holes in ceilings in areas accessible

to incarcerated persons at a large

GDC men’s prison in 2022. GDC

acknowledged that some holes DOJ

observed at this facility were caused

by “inmate vandalism.”

37

renovated locking systems or otherwise maintain facilities after fixing broken fixtures,

windows, walls, ceilings, and other components of facilities.

We were told repeatedly by incarcerated people, including those who work

maintenance details and are responsible for facility repairs, and some staff that an

enormous amount of repair work was undertaken prior to DOJ’s site visits to each

prison. Despite these efforts, during site visits, our experts observed physical building

and maintenance issues that affect security, including broken or exposed electrical

outlets and wiring, metal fixtures, large holes or patched areas in ceilings and walls,

and small holes and cracks in walls and windows.

GDC also fails to comply with its own policies to regularly evaluate, test, and document

the condition of its security infrastructure and systems. Internal audits confirm that

GDC fails to take necessary steps to ensure its prisons are secure. For example,

several 2023 facility audits found that GDC fails to perform required checks of windows

and doors to ensure they have not been cut or modified. Several facility audits also

found that GDC fails to maintain accurate key and tool inventories and to document

key counts and checks. For example, one 2023 facility audit of a close-security men’s

prison noted inconsistencies in accounting for and inventorying tools, and a lack of

consistent control and documentation regarding chemical agents, weapons, and

inventory. GDC’s failure to maintain control of such sensitive equipment as keys and

tools exposes the population (and staff) to an unreasonable risk of harm, because

discrepancies and failures to follow policies in these areas can compromise the

physical security of the facilities’ doors and gates and can facilitate the use of weapons

and other contraband.

4. GDC’s ineffective classification and housing systems expose

incarcerated persons to an unreasonable risk of violence.

GDC’s classification and housing systems do not function properly. GDC does not

conduct timely and accurate classification and segregation reviews due to staffing

shortages and the incomplete data in GDC’s automated systems. Moreover, GDC

does not enforce classification housing assignments, enabling gangs and other

security threat groups (STG) or other incarcerated individuals to dictate housing

assignments and other aspects of daily life.

GDC has a computerized classification system, the “Next Generation Assessment”

(NGA) tool. GDC officials explained that the NGA tool was developed for GDC, and

that it uses data entered into GDC’s correctional management database to calculate a

security-level score for each incarcerated person. Thus, individuals’ security scores

should be updated based on new STG information, incident reports, disciplinary

reports, and other inputs as they are entered into the system. A computerized system

38

like this can be an effective

CONSEQUENCES OF HOUSING AND

tool, but it must be

CLASSIFICATION FAILURES

combined with individual

classification and re-

In May 2022, a 21-year-old man was killed by his

classification reviews by

cellmate at Calhoun State Prison following multiple

staff, and the system must

failures in GDC’s classification and housing systems.

receive relevant updated

information such as serious

The homicide occurred after staff moved the assailant

incident occurrences.31

out of segregation, to general population, and then

back to segregation without following classification

GDC fails to ensure that

and housing assignment procedures. When staff

classification reviews are

moved the individual back to segregation, he

conducted by qualified staff.

requested to be placed in a particular cell, and staff

We found that staff do not

housed him there with a cellmate. The next day, the

consistently implement the

two cellmates told an orderly that they wanted to be

agency’s own classification

separated, which the orderly communicated to an

timelines and procedures,

officer.

such as those that mandate

classification and

One day later, an orderly saw the individual being

segregation reviews and

beaten by his cellmate. The man died. The autopsy

counselor meetings. GDC’s

revealed blunt force trauma injuries and a stab wound

internal audits from several

to the neck.

prisons in 2023 found

GDC closed its criminal investigation without a

delayed initial counseling

thorough administrative review into a breakdown of its

sessions, inconsistent or

classification process. An administrative review

inadequate scheduling and

should have addressed the staff errors, as well as

completion of counseling

errors in housing records, and indications of personal

sessions, and incomplete

connections between a staff member and gangs.

classification

documentation. These

There was no evidence of discipline or counseling in

shortcomings may in part be

the personnel files of three employees whose errors

due to understaffing of

were identified in the investigation as relevant to the

counselors, who are tasked

man’s death.

with conducting

31 Such computerized classification systems also must be validated for the specific incarcerated

populations and periodically re-validated. In addition, housing audits should be done to ensure the system

output is in place in the facilities. GDC personnel claimed that the NGA tool has been validated, although

GDC did not provide us with a specific date or year that any such validation took place. It appears the last

validation was at least a few years ago, and it is unclear whether GDC plans to re-validate the system, and

if so when. Despite our repeated requests, GDC did not provide documentation to confirm such validation

or re-validation testing or to explain the criteria, formulas, and other scoring mechanisms the system uses

to determine custody levels.

39