Report of Arthur M. Wallenstein And Curriculum itae Preliminary Report on the Death of Andrew Westling By: Arthur M. Wallenstein What follows is a preliminary report on the death of Andrew James Westling, who died in custody at the Nisqually Jail in Olympia, Washington on April 12, 2016. was retained by the law ?rm of Budge lleipt, PLLC to review records pertaining to Westling?s death and to provide my opinions about facts and circumstances leading up to and surrounding his death. With nearly 50 years of experience in corrections, including nine years as the Director of the King County Department of Adult Detention which operates Washington state?s largest county jail system, I was asked to focus on the policies and practices of the Nisqually Jail and the actions and inactions jail personnel during the roughly 24 hours Westling spent at the jail up to and including his death. This report is based on the records and information I have reviewed to date, which are listed below. My opinions in this report are subject to modi?cation should additional information become available to me. Summary In my professional opinion, Nisqually jail personnel failed egregiously in their individual and collective duties to secure medical care for Westling from 6:00 pm. on Monday, April 11, 2016 through his death approximately six hours later, just after midnight on Tuesday, April Nisqually jail personnel also failed to properly monitor Andrew during those 6+ hours. Jail personnel repeatedly violated basic protocols, policies and basic correctional standards of care. These violations were so blatant, so continuous and so ongoing as to clearly indicate general failures in training, a custom of disregarding inmates in need of medical care, a failure ofsupervision, and/or a general institutional failure to comply with minimal standards of care in the correctional setting. Moreover, the City of Yelm should have had systems in place ensuring, at a minimum, that the Nisqually Jail was operating in such a way that detainees were provided with constitutionally- mandated medical care. Background and Quali?cations Until my retirement last year, I worked as a corrections administrator for over 40 years. or most of that time I directed county jail systems in Washington State, and Maryland. From 1990 through 1999 I served as Director and Jail Administrator for the King County Department of Adult Detention, where oversaw two maximum-security detention facilities with a combined total of2,490 beds. While in King County, I successfully led the agency?s effort to attain accreditation from the National Commission on Correctional Health Care including three successive accreditation surveys that found us in 100 percent compliance with NCCIIC standards. Following my tenure with King County, I served for 15+ years as Director ofAdult Corrections in Montgomery County, Maryland, where I managed two maximum?security jails and other programs. 1 As I did in King County, I helped Montgomery County achieve 100 percent compliance with the standards. In the course of my career, I have received a number of recognitions, including the Bernard Harrison Lifetime Achievement Award in Correctional Health Care, presented by in 2004. I have also served on numerous boards, commissions, and task forces, including the Metropolitan Council of Governments, where I have been elected to serve a second term as chair of the committee covering adult corrections and jail operations in ten northeast jurisdictions. I also served for 13 years on the advisory board of the .S. Department of Justice?s National Institute of Corrections, appointed ?rst by Attorney General Janet Reno and later by Attorney General Eric Holder. In addition to my career as a corrections administrator, I have taught corrections and criminal justice at various colleges and universities, including Temple University, the University of Maryland, and the University of Washington. I currently teach correctional administration and criminal justice at the University of Maryland University College and Montgomery College in Rockville, Maryland. A more detailed curriculum vitae is appended to this report. Materials Considered I reviewed the following materials in deveIOping my opinions in this matter: 0 Nisqually Indian Tribe, Website - Department of Corrections, Washington State, updated through August 23, 2016; Detective Mason, Interviews (Nisqually Detention Facility Staff Members), May - June, 2016; Nisqually Indian Tribe, Nisqually Corrections - Housing Post Order, 2012; Nisqually Indian Tribe, Nisqually Corrections Officer Training Program (undated) current; 0 Materials compiled by Lacey Detective Mason. Incident Investigation, 2016; Nisqually Corrections, Inmate Admission, July, 2014; Nisqually Corrections, Medical Services - Death or Injury, March 3, 2004; Nisqually Indian Tribe, I?guallv Jail Services Agreement with City of Yelm, December 10,2013; - Office of the Inspector General US Department of the Interior, Bureau of Indian Affairs Funded and/or Operated Detention Programs, Report No. February 2016; 0 Todd Minton, "Jails in Indian Country, 2014," Bureau ofJustiee Statistics, October, 2015; 0 American Correctional Association, Core Jail Standards, First Edition, Alexandria, Virginia, 2010. Constitutional Duty to Provide Necessary Health Care to Prisoners and General Observations Basic correctional standards of care are informed by legal precedent. Ever since the United States Supreme Court decided the case of Estelle v. Gamble in 1976, it has been clear that prison officials have a constitutional duty to provide inmates in their custody with access to necessary medical care. As the Court explained in that case: An inmate must rely on prison authorities to treat his medical needs; if the authorities fail to do so, those needs will not be met. In the worst cases, such a failure may actually produce physical ?torture or a lingering death,? the evils of most immediate concern to the drafters of the [Eighth] Amendment. In less serious cases, denial of medical care may result in pain and suffering which no one suggests would serve any penological purpose. The infliction of such unnecessary suffering is inconsistent with contemporary standards of decency . . . . Estelle v. Gamble, 429 US. 97, 103?04 (1976). In order to ensure that they comply with the Eighth and Fourteenth Amendments, jail officials must ensure that the jail has adequate policies and procedures that guarantee inmates will receive timely and necessary care for serious medical needs. Further, all institutions must train jail staff in how to recognize the need for medical care and how to implement the jail?s policies and procedures to ensure that needs are met, whether the need is emergent, urgent, or routine. lnmates? access to necessary care must not be affected by staff?s personal beliefs or by the medical judgments ofnon-medical staff. These duties are constant, and jail stuff must be cognizant of them at all times while on duty. Inmate medical care may be provided by physicians and other licensed health care providers employed by the jail, contracted providers, or community providers, but regardless of who is providing the care, jail stuff must be trained to ensure that inmate have access to those providers as necessary, 24 hours a day, 7 days a week. This is particularly important in jail settings, where inmates are booked and released at all times of the day. A prisoner?s access to necessary care cannot be dependent upon which particular staff members happen to be on duty at any given time. I learned that the City of Yelm had a history of seeking jail beds from the Nisqually Tribe and that the Nisqually Tribe made secure jail based detention beds available to the City of Yelm, their Police Department and other criminal justice agencies for per diem payments. The Nisqually Tribe appeared to hold police arrestces and sentenced persons for the City of Yelm in cases where detention/incarceration involved both pretrial and designated periods of sentenced time generally less than 12 months. This case at hand (Andrew James Westling) occurred under a formal contract between the City of Yelm and the Nisqually Tribe. The contract that covered the period where Andrew James Westling died in custody was signed on December 10, 2013. It would cover the period January I, 2014 and extend 5 years. It is to the best of my understanding still in effect at this time. Andrew Westling was booked into an Indian Country Jail (Nisqually Tribe) and was at all times under the care and responsibility of the Nisqually jail pursuant to that contract. The Nisqually Tribe promised to provide 3 bed spaces "that would be dedicated to Yelm for its prisoners." (contract, page 1). The Nisqually Tribe made bed space available to several other local municipalities?urisdictions (approximately 15) in exchange for per diem payments negotiated and then covered by contract. I am unable to tell if the City of Yelm conducted any reviews, inspections or evaluations of the contract jail site. I do not know if the City of Yelm reviewed correctional practices to ensure that the Nisqually facility met basic correctional standards and constitutional practices regarding the care and custody of the persons the City of Yelm brought there for detention. I do not know if the City of Yelm utilized a contract monitor to review health care and medical care at the Nisqually facility. Given the importance of medical care and health care within a correctional setting, the City of Yelm should have had a documented process to ensure that the Nisqually jail met constitutionally accepted levels and elements of service delivery to ensure the life safety of their arrestees. Contract review is a serious matter. One does not simply sign an agreement and then assume that all responsibility rests with the party providing the service. When I served as Director in Montgomery County, Maryland, we operated our own health care/medical program. However, we did contract for medications and pharmacy services. I personally visited our contract pharmacy with our Correctional Health Care Administrator to review the contract elements and see exactly how medications were filled and transferred to our agency. I did this myself (no delegation) because of the critical importance of health care delivery in general and medications/pharmacy services in particular. Yelm should have used a contract monitoring methodology to ensure all constitutional provisions and accepted correctional standards were followed. Correctional agencies and staff members who follow core standards and constitutional practices understand that jail inmates cannot provide for their own medical care while in jail custody. They are wholly dependent or at least in large measure dependent upon jail staff (including health care staff, whether jail employees or contract professionals) to ensure they have access to these services. As long as care cannot be sought and completed on their own, inmates rely on the staff members of the agency holding them to guarantee that core principles are followed to ensure they have access to medical services. Every teaching and operational component of correctional health care has been clear and without deviation since 1976. Care principles have not changed since the United States Supreme Court handed down its decision in Estelle v. Gamble. I have that taught the guiding principles of Estelle must be understood and followed on every cell block and in every jail housing unit and booking area in this country. Staff are wholly responsible for ensuring that every inmate has access to medical care. Personal beliefs or medical assessments of non-medical staff do not enter into this process or responsibility. Every staffmember should have been trained to understand and implement procedures that guaranteed inmate access to health care whether it was at shift change or the middle of the night and regardless who was on duty and who was designated as the supervisor or officer in charge of the facility. Following constitutional guidelines of access to health care is a constant of mandatory practice. This is made abundantly clear on both the website of Nisqually Corrections and their operational policies and procedures. Yet, Nisqually jail failed across the board from top to bottom and beginning to end to provide Westling with access to this most well documented and constitutional right. Analysis of Events Preceding Andrew Westling?s Death The written policies of the Nisqually jail re?ect a general awareness by the authors of the policy of the jail?s duty to provide inmates with necessary care 24 hours a day. However, it also appears that the officers on duty on April 1 and April 12, 2016 were either not aware ofthese duties, were not adequately trained on how to execute them, or disregarded them. The first sign that something might be wrong with Westling came shortly after 2:00 or 3:00 on Monday, April 1 1, following a phone call between Westling and a judge. Officer Michael Althauser, who was with Westling at the time, reported that he seemed anxious. A few hours later, at approximately 6:00 pm, Of?cer Althauser heard Westling banging on the door of his housing unit and observed him through the window holding his neck. He pulled Westling out of the unit, at which time Westling told him about his heart condition. Westling told Of?cer Althauser that he had an abnormal heartbeat and that the last time his heart condition acted up he had to be resuscitated in an ambulance. Officer Althauser reported that ?at that moment, I was like, ?Okay, you?re not going to stay here. I don?t want your heart condition to act up in here where somebody?s going to check you in 30 minutes and it?s going to be too late.? At this point, any reasonable, properly trained corrections officer would have contacted medical staff to report Westling?s statements about his heart condition. If no medical staff were available, a reasonable, properly trained officer would have called 91]. Officer Althauser did not do either of these things. Instead, he called another officer on duty, Michael Pino, to ask if there were any cells available in the booking area where Westling could be placed for medical watch. According to Officer Pino, Of?cer Althauser told him that Westling was ?showing anxiety? and that he had mentioned something about ?a rare heart condition he had." Westling also told Officers Althauser and Pino that he used to take medications for his heart condition but that he stopped because he didn?t have the funds for them. Failing to summon medical aid for Westling following his 6:00 pm. complaints was a violation of basic standards of care for correctional staff. In addition, I note the following: I. When ()flieer Althauser moved Westling to llolding Cell #3 for Medical Observation he completed a special form for close supervision. It is called - "Inmate Special Housing Record 5 Sheet." The Lacey Police Detective who was assigned to come to the Jail immediately after the prisoner's death found the observation log sheet on the door of the inmate's cell. 1119 Special observation log was not filled out - there were no entries regarding any element of Westlingis time in this special observation and watch status - NOTHING. When Westling was moved to Holding Cell #3 for medical observation no health or medical staff member or contractor was called - he remained without any professional assistance even though the Nisqually ia_il made clear that medical services are available 24 hours daily. There was no one present with skills to conduct, carry out or support any "Medical Observation." No professional health care guidelines were received from the contract physician or from any other health care professional because they were never called. Althauser had concerns but failed to carry out the one action most needed - refer Westling to a health care provider and secure that provider?s presence. Officer Althauser completed his shift and left the facility. Westling was now in Ilolding Cell #3 under the purported visual supervision of Correctional Of?cer Michael Pino. Pino also was at the end of his shift but remained to receive Westling in his new designation - Holding Cell #3 - Medical Observation. Of?cer Pino was not a professional health care provider. He claims to have felt or understood that anxiety from Westling?s earlier call with a judge was the reason for being placed under Medical Supervision. But Officer Pino was in no position to make any medical determination about any element of Westling?s condition. As a non- medical staff member, it was completely improper for him to suggest he understood why Westling was experiencing the of which he complained. Non medical staff do not make health care decisions. Onlv a professional health care provider could determine if heart/cardiac matters were present and how they should be addressed but no one with medical expertise was called, contacted or sought out to assist. One staff member after another arrived false conclusions because they never called upon their health care colleagues or a community based service provider to assist. Officers Althauser and Pine appeared to work together and went through the administrative steps to move Westling to Holding Cell #3 for Medical Observation but took no steps to provide Westling with access to a medical evaluation or healthcare services. A full 6 hours prior to his in-custody death this prisoner had been engaged in direct conversation on his health condition. had evidenced concerns by banging on his cell door and had been moved to a holding cell for Medical Observation. Health care words and phrases like "anxiety" and "medical observation? were used by non?medical security staff. No matter how well intentioned they had no standing and no designation to make any medical decisions. Again no calls were made to seek out any health care assistance or any health care providers. In and of itself, this violated basic corrections protocol. From the moment that Of?cer Althauser ?lled out the masthead of the Special Management Form it was never ?lled out on the door of the Holding Cell where Westling was placed this is a gross failure to adhere to the jail?s own standard operating procedures. 6. 10. By 6 pm. on April staff were aware of various matters that could clearly impact the health of inmate Westling. He had self-reported new information that was not shared at Booking and Intake regarding serious cardiac issues. He reported needing resuscitation in an ambulance during a similar previous cardiac episode. His complaints were noted - he was moved to a special observation status, comments were offered by non-medical staff about anxiety as opposed to cardiac issues yet not a single call was made or effort made to seek out a trained health care staff member, contractor or community based provider. The essence of a Correctional Officers responsibility was to report Westling?s complaints to medical msonnel so that access to health care and treatment (if needed) could be provided. No health staff were contacted - NONE. Westling?s evolving health care situation was first made known by him to Of?cer Althauser in Housing Unit 2 shortly prior to shift change around 6:00 pm. on April 1 1th. From around 6:00 pm. on the 1 1th until Emergency Medical Unit (91 1) was called at 12:52 am. on April 12th (well after Westling was deceased), no contact was made by the staff of the Jail with any health care professional- NONE. This is an egregious failure by correctional staff Throughout the entire period of Westling's confinement in the Nisqually Jail until 911 was contacted after his death in Holding Cell #3 there was virtually no mention of health care delivery, medical service delivery, referral to a physician or professional health care staff member/ provider, transfer to a hospital, movement to a community based program or even a call to 91 l. The entire record until approximately 12:52 am. on April 12, 2016 reads as there is no program of health care, medical care or urgent/emergency evaluation and services available to any prisoner within the Nisqually Detention Facility absent one vague reference to Westling?s need for a ?doctor? at some time in the future. Staffon duty failed to follow their own policy which notes "The facility's physician provides a wide range of services such as 24 hour on call consultation, emergency referrals, medication oversight, and on - site evaluations and examinations." (Nisqually Indian Tribe Website, Department of Corrections. Programs and Services, page 3). The physician was never called, an alternative to the physician was never called, 911 was never called until Westling was found unresponsive more than six hours after his initial complaints, Facility Administration was not contacted nor is there any record of anyone calling a health care professional regarding Mr. Westling. After repeated expressions of concern by the msoner Nisqually Jail staff called no one until he was found unresponsive and likely dead. Correctional Of?cer Edna David first had contact with Westling when she came on duty after shift change on April 11th. She observed Westling in his current and final location - Holding Cell She reports that between 7:30 and 8:00 PM Westling was again "pounding on the door" and "said that he was having heart skip . . . skipping beats." He was leaning over the toilet and had a drenched towel over his head. She was told he was moved to Holding Cell #3 for medical observation. Officer David properly reported this to her supervisor (Acting Supervisor/Officer in Charge) Arron Robertson. Yet, no calls or contact are made to any health careprovider by either of them, or by_anyone else. ll. 12. 13. 14. 15. 16. Knowledge of potentially serious health care concerns as of 7:30-8:00 pm. had now been received and documented by Correctional Of?cer Michael Atlhauser, Correctional Officer Michael Pino, Correctional Officer Edna David and Acting Supervisor/Officer in Charge Aaron Robertson and not a single person has sought to contact the physician on call, any other designated medical staffmember, 91 1 emergency services or another community based health care provider. No Contact. The record is devoid of any evidence that any exigent circumstances interfered with what basic core practice mandated - engaging the 24/7 contacts with professional health care staff. At least four correctional officers have, by 7:30-8:00 pm, made medical decisions by omission - failure to report anything to a proper health care authority. They were making ongoing judgments far beyond any evaluation, review, guidance or possible treatment for Westling or any guidance regarding Westling. There can be no explanation or rationale for their failure to contact a health care_professional or contact a communitv based provider or get him to a hospital emergencv room for assessment and care. This chronology between 6:00 pm. and until he was discovered unresponsive at approximately 12:50 am. is almost beyond my understanding as a Jail Administrator. It borders surreal in nature. Correctional Officer Arron Robertson (Acting Supervisor/Officer in Charge) was apparently supervising this shift because a regular supervisor was not present. Of?cer Edna David directly reported to him that Westling is banging his door, talking about cardiac concerns and soaking his head with a towel while standing over the toilet. David and Robertson find no medical information in his file and they make a further medical decision not to contact a health care professional. This was entirelLinapperriate and a gross deviation from the standard of care. Correctional Officers Althauser and David were fully clear that no calls were made to a physician or nurse or other health care provider. Acting Supervisor Robertson noted he was unclear about calls. Yet, he had overall responsibility. If he was unclear, that is further evidence that no calls of any kind were made seeking evaluation, review, guidance or possible treatment for Westling. The Acting Supervisor knew of the comments made after booking to his Officers yet he did nothing. Robertson grossly neglected correctional standards in failing to make any contact with professional health care staff. He never even discussed this option with those staff reporting to him. He called none of the officers who had left after their shift to seek any further information, nor did he seek information from Westling directly. As a jail administrator reviewing this case, it de?es the imagination to try and understand why no one made any attempt to seek guidance or a review from the physician who provided health care services to the Nisqually Facility or any other provider. Without formal discovery and depositions it is difficult to even entertain how the information these officers received, both as orally reported and as written down, could generate no implementation of the policy to make medical services available to Westling. There is no justification for Acting Supervisor Robertson to suggest that the absence of information provided at booking and intake on speci?c medical concerns renders all that 17. 18. 19. 20. 21. 22. followed in the evening as excusing his responsibility, above all others, to seek any medical guidance. The Nisqually facility is not a prison where sentenced offenders are received infrequently. It is a local jail. It is further a detention facility that serves not only the Nisqually Reservation but some 15 local jurisdictions who book arrestees day and night. Jail arrestees generally come right from the streets and many have a wide range of health care needs. Some needs are not apparent upon booking but arise later. It remains unconscionable that no professional medical support and guidance would have been sought in the Westling case. A fair reading of the Nisqually Housing Post Order shows that segregation of an inmate for ?medical observation? carried with it mandatory 15 minute checks. Yet, no such checks were ever documented. Whether it was an overt failure to provide access, an error or omission or a belief it was not needed, this failure to check on Westling is deliberate indifference_t_o_ the potentially serious medical needs of an inmate. A physician or health care professional determines what is serious or urgent or an emergency. Line correctional staff erred over and over again in failing to check on Westling, who was being held in medical segregation, and further failed to provide Westling with prompt access to health care, or indeed, with any access to health care from a trained professional. If the Acting Supervisor/01C Arron Robertson was unsure of what to do he need only follow his post orders - "'Staff seek guidance of their supervisors and the administration in order to make decisions and address issues as they arise.? (Nisqually Corrections - Housing Post Orders (2012) p. 4.) Yet, there is no evidence or commentary that OIC Arron Robertson sought any guidance or direction as he received comments and information regarding Westling from correctional officers under his direction. Seeking guidance is a standard practice in every correctional facility in this country. Until 911 emergency medical services staff arrived to respond to Westling's unresponsive status, not one single health care or medical professional touched, interacted or consulted on any element of this case. It was as if the Nisqually facility was operating outside of every facet of corrections and health care core practices that are accepted all over this country in the field of corrections and jail?based corrections in particular. It was a gross deviation of how a jail should be operated - how to operate without any ?gment of concern for professional medical practices. No staff member asked any questions of any medical provider, contract physician or any other health care professional. They operated outside any understanding of core constitutional practices that, since 1976 (Estelle v. Gamble), have been the guiding focus ofcorrectional health services. Every prisoner?every human being in the Nisqually jail?has a right to medical services. They must have access to medical services as an undiluted constitutional mandate. Correctional non-medical staff own the "access" linkage. Once access is provided, decisions and outcomes rest with medical professionals. Whether or not Westling specifically asked for a nurse, doctor, paramedic or any other medical professional is not relevant to the duty of the corrections of?cers to initiate a call for 23. 24. 25. 26. 27. 28. medical assistance. Westling clearly and unambiguously expressed his concerns, showed physical signs consistent with these concerns, and indicated that he had a documented history of cardiac problems requiring past ?resuscitation? and medication. These complaints, in and of themselves, easily triggered a duty of corrections officers to summon medical care for Westling. The policies, procedures and correctional guidelines at the Nisqually jail were not written in a vacuum. No jail of any substance in America operates without medical resources or without utilizing those professional resources on an ongoing and regular basis as needed. Training, experience, core guidelines and case law demand attention to this highly litigated and abundantly clear area of responsibility At any time between 6:00 pm. on April 1 1, 2016 and prior to ?nding Westling unresponsive and likely dead at or about 12:50 am. on April 12, 2016 staff could have contacted the on call physician, called jail administration for assistance, called 91 1, and/or sent Westling to a hOSpital emergency room out ofconcern for his well?being. The failure to do so is inexcusable. The failures of correctional staff to summon any provider, conduct mandatory checks on Westling, contact supervisory staff if they were unclear about their duties, or do anything else to address his well?being reflect and institutional failure to train and a total failure of supervision. Whether these were failures by the facility itself or the City of Yelm or, likely both, the critical point is that the failures occurred and were likely occurring at an institutional level. The lack of training and supervision is addressed in more detail below. The Nisqually jail?s website highlights the availability of direct support: "The facility's physician provides a wide range of services such as 24 hour on call consultation, emergency referrals, medication oversight, and on - site evaluations and examinations.? (Nisgually Indian Tribe, Department of Corrections Website, p. 3 - in effect on April 11 - 12, 2016). Westling died without any element of that policy being implemented or engaged. The policies and procedures of Nisqually Corrections - Housing Post Order (2012) starts with the following introduction: "The information contained in these post orders will provide staff with overview information and instructions for most routine and emergency situations." Direct guidance is then provided: "Staff is expected to seek the guidance of their supervisors and the administration in order to make decisions and address issues as they arise." (Nisqually Corrections Housing Post Order, 2012, p. 4) Even this direction was repeatedly violated in the Westling case. Ifstaff members coming on duty at 6:00 pm. on April 1 1th did not understand why Westling had been placed on medical observation, they could have held over the previous shift or immediately contacted the on call physician or other medical professional. The Officer in Charge (OlC)/Acting Supervisor should have known to seek medical guidance as soon as it was reported to him by staff that Westling had provided further medical/health information regarding his cardiac situation, past cardiac episodes and then banging on the cell door to alert staff to his irregular heartbeat. This required no evaluation or medical knowledge. It is an obvious medical need. The Nisqually jail?s operating guidelines state as 10 29. 31. 32. 33. 34. 35. follows: ?When indicators arise re?ecting signi?cant health problems, mental health concerns and/or possible suicide risk immediately contact the shift supervisor." (The Shift Supervisor is to contact his/her supervisor or administration ofthe 24 hour on-call physician). These standards were clearly violated. Of?cer Althauser?s written documentation of Westling?s complaints and history should without question have prompted contact to the on?call physician for guidance and possible transport to a hospital emergency room. Westling died without ever having received any professional medical evaluation or treatment. This, combined with the speci?c staff reports and observations provided by Correctional Of?cer Michael Althauser, Correctional Officer Edna David, Correctional Of?cer Michael Pine and Correctional Of?cer Robertson provide more than enough substance, concern and justi?cation to seek professional medical services. . Nisqually Corrections guidelines are clear: inmate is to be refused access to medical care. Staff will not make medical decisions." (Nisqually Corrections - Housing Post Order. 2012 - Sick Call and Access to Health Care, p. 19.) Staff needed no approval to contact the on-call physician. In an emergency they could have sent Westling directly to the hospital or called 91 1 (as they did after it was too late and after he had likely been dead for at least 40 minutes). Why should Nisqually Corrections policies and procedures provide for 24/7 on-call physician availability if the services were not going to be used? This single issue illuminates every element of the Westling tragedy. Training is without exception a critical element - about as important as it gets at the line correctional officer level. Having written policies and procedures is a core element of on point and constitutional correctional operations. Training is required to give the policies and procedures operational credibility and ef?ciency and the reality of veri?cation of actually doing the work. The actions and omissions ofNisquallyjail staff suggest a profound lack of training. Given the seriousness of this case it is essential if litigation moves forward that the training record of every staff member on duty from April 1 I and 12, 2016 be provided and reviewed in detail. Not only is new employee orientation training important but also yearly in service or updates to ensure that core elements are covered. Lack of training will often cause constitutional violations. Training records must be documented in any correctional agency. If the administration of a correctional agency fails to meet training criteria and full staff coverage. the entire agency has been cheated and the inmate population is put in risk. Administration and management owes every staff member serious training in every area of core operations. Staff members must have veri?ed training, consistent with jail standards of care. It is the responsibility of the municipality having custody of the inmate (the City of Yclm) and its contract provider (Nisqually) to ensure that this training is provided. Throughout the reading of the documents, interviews with staff members and copies of of?cial log entries there is not a single notation of anyone suggesting that a physician should 11 be called. Staffmember after staff member did not report in response to questions from the Lacey Detective/Investigator that policy and procedure provided for a physician being on call 24/7 as needed. The absence of any staff based references strongly suggests that they were not trained in this singularly?obvious training element; that they should simply contact the physician or provider for guidance and assistance. If line corrections officers in the Nisqually jail were not speci?cally trained on physician 24/7 on call capability and how to make this happen, this is an egregious violation. 36. What has the City of Yelm done to investigate or institute remedial action after this tragedy? Westling was their detainee. Has the City of Yelm done anything to understand how this could have occurred, where the failures lie, and what, if anything has been done to prevent a future tragedy of this nature? So long as Nisqually houses Yelm?s inmates, it is Yelm?s responsibility (as well as Nisqually?s) to do so. 37. If the Nisqually jail?s policy only required that jail personnel summon emergency services when an inmate was ?unresponsive,? or near death, this this would be grossly deficient and may have been directly related to Westling?s death. Likewise, if the jail policy only required summoning medical care for medical complaints expressed at booking and intake?without regard to later problems expressed by the inmate?this would be a grossly deficient policy contributing to Westling?s death. If the jail policy only required that jail personnel summon a provider if the inmate used particular language in his verbal complaints or imposed other unreasonable conditions as a prerequisite to medical care, this, too, would be a grossly deficient policy. 38. Throughout all of the documents, notes and elements of discussion that I have read, I find no mention, presence or on site involvement 01?senior management from the Nisqually jail. It is true that this incident covers a very small frame of time and activity, but I ?nd it highly unusual and concerning not to read any reference to any Nisqually management or administration involvement or presence in any element of jail operations. There is almost a singular avoidance of any reference to persons of authority, professional expectations or use of professional contract resources in the health care area of practice. 39. Three Nisqually Corrections Forms document why a medical provider should have been contacted. These include: a) Segregation Referral - April 1 1, 2016 1800 Hours (CO Alhauser) b) Nisqually Special Housing Unit Record Sheet - started April 1 l, 2016 - 1800 Hours (CO Althauser) c) Incident Report - Medical Incident - April 11, 2016 - 1815 Hours (CO Althauser) Acting Supervisor Arron Robertson noted in his post-death interview that Westling had noted no medical complaints upon arrival of 4/11/2016 beyond a STD. However, he failed to recognize that subsequent written and verbal information brought to his attention must be 12 40. 41. 42. reviewed and acted upon. These three forms above establish documentation that this arrestee/prisoner (Westling) announced problems of a serious nature to any correctional staff members on duty and nothing was done to seek professional medical assistance. In most jails, when a prisoner is placed on special observation (especially medical or mental health observation) a mandatory observation sheet is placed right on the cell door or in a mandatory digital file to be completed according the local policy The Nisqually policy on this status notes a "15 minute watch" was required. Yet, nothing was recorded. No mention of any 15 minute watches, food, comments regarding the prisoner or any supervisor initials. It defies explanation that after medical observation was selected for Westling and a Special Housing Form was added that no action was taken and no 24/7 professional medical contact was made. The Nisqually Jail?s Special Incident Form removes any doubt about the need for professional medical review. CO Althauser reiterates that while working in General Population (House 2) Westling began to bang the cell door, report his cardiac condition and noted a previous life safety incident consistent with his then?existing Althauser reports that he called for an I?available of?cer to come to the housing unit so that Westling could go into a medical watch until a doctor comes to check on him." Clearly, a serious or potentially serious problem existed. This was about as clear as it could get that the Nisqually 24/7 physician contact policy should be called into operation. Yet nothing happened to respond to Westling?s medical complaints. Correctional Of?cer Edna David notes that she never saw the forms until shortly before Westling was found unresponsive. She also reported Westling's cell door banging and cardiac-focused comments to the Acting Supervisor. Nothing was noted on the Special Housing Unit Record Sheet in response. The Acting Supervisor paid no attention to the personal/direct comments of Westling that he had serious medical concerns. N0 "15 Minute Watch" notations can be found. CONCLUSION Andrew Westling never should have died in the Nisqually Jail without the opportunity to receive professional medical review and assistance. I have rarely, it?ever, seen such a blatant violation of basic corrections standards of care, both on an individual and institutional level. Report ed: Ai? Artht M. Wallenstein 13 BackgroundInformation - Arthur M. - PageI July 30, 2016 ARTHUR WALLENSTEIN artwallenstein@gmail.com [7525 Princess Anne Drive OIney, Maryland 20832 (301) 260-2953 - Home/Of?ce (301) 412-7424 Cell summer through August 30th EDUATION Undergraduate: Graduate: TEACHING Georgetown University, School of Foreign Service, Washington, DC. Major: Political Science, BS, 1967 Dean's List. Who's Who Among Student Leaders, Selected as Intern, US Department of State, Bureau of African Affairs - June, 1966 - une 1967. University of Graduate School of Arts and Sciences. Major: International Relations, M.A., 1968. candidate, National Science Foundation Fellowship. Columbia University, Special Student, 1969 - course work in South African politics. University of Chicago, Special Student, 1974 - course work in the Hispanic Community and its problems. University of Maryland, Department of Criminology and Criminal Justice, College Park at Shady Grove Campus (teaching 400 Ievel advanced classes - undergraduates - starting January, 2015) - current 2010 Present: University of Maryland University College, appointed Adjunct Associate Professor, Criminal Justice Program teaching advanced 400 level courses in Correctional Administration and core courses in Introduction to Corrections.- current 2003 Present: Montgomery College, Rockville, Maryland, Adjunct Faculty member teaching courses in Introduction to Corrections and Administration ofJustice.- current I998 I999: University of Washington, Society and Justice Program, Adjunct Instructor taught undergraduate senior level courses in Adult Corrections. 1978-1990: Temple University, Visiting Associate Professor (promoted I987), Criminal Justice Department, Philadelphia, 1987-1990: St. Joseph's University, Instructor, and Graduate Program in Criminal Justice, Philadelphia, Background Information - Arthur M. Wallenstein - Pagc2 Field Research: CORRECTIONS EXPERIENCE 10/99 March, 2015 (Retired, 3/13/2015) 8/1990- 10/99 Teaching positions were adjunct assignments while serving as Director/Warden in Bucks County, King County, Washington and Montgomery County, Maryland. Work in Africa (Namibia, Zimbabwe, Lesotho, Swaziland, and South Africa) to study the relationship between racism and international politics (1970). Visits to correctional institutions in Egypt and Israel (1982). Visits to refugee camps, Thai-Cambodian Border (1987) on behalf of the U.S. Committee for Refugees. Publication - Family Reunification for Khmer on the Thai?Cambodian Border, July 1988. Director Montgomery County Department of Correction and Rehabilitation, serve as the Department Director for Adult Corrections in Montgomery County, Maryland. Manage the county correctional system including two maximum security jails of 1200 beds with major program involvement in substance abuse treatment, education, workforce programs and related correctional programs. Also includes a Pre?Release Center (community corrections and reentry) with 175 beds and model reentry programs, and a full Pretrial program in the community with an ADP of 1600. Department is accredited by the American Correctional Association National Commission of Correctional Health Care at 100% and Correctional Education Association (CEA) at 100% compliance. Full compliance (100%) Prison Rape Elimination Act (both Jails and community based Prerelease and Reentry Center), March, 2015. Director - King County Department of Adult Detention, Seattle, Washington Joint appointment as Director and Jail Administrator. Responsible for cabinet-level senior management of King County's corrections system, including two maximum-security prison/detention centers (1,600 beds and 890 beds), Work/Education Release (190 beds), and Electronic Home Detention (70), substance abuse treatment center (296 beds) with King County Health Department. Supervise staff of 600 with a $70 million budget. Multiple-union environment with full labor relations responsibilities. Regular testimony before 13-member County Council. New Regional Justice Center project development under my supervision Background Information - Arthur M. - Pagc3 8/1977-8/1990 2/1974-8/1977 8/1972-2/1974 (892 beds--direct supervision--p1us courts, police, prosecutor, defense, and related agencies opened, March 1997). health care accreditation - three successive/successful conclusions 100% county correctional agency and health department had lost health care accreditation and were involved in major federal litigation I led the effort to reaccredit the mental health and health care status of the agency successful and litigation was concluded. Director - Bucks Countv Department of Corrections, Bucks County, Joint appointment as Director and Warden, Bucks County Prison. Responsible for administering county corrections system, including maximum-security prison (600 beds) and a 230-bed community-based work release center. Direct participant in planning and design of new generation direct-supervision prison opened June 1, 1985. Supervise staff of 225 employees. New prison selected by US. Justice Department, National Institute of Corrections, as training site for direct-supervision jail operations. Planned and coordinated design of new work release facility (270 beds), 1988-1990. Represented prison wardens numerous times before House and Senate Judiciary Committees General Assembly), 1979-1990 in following areas: mental health, community service/restitution programs. Four times NCCIIC Health Care Accreditation and two times ACA Community Residential Program Accreditation. Illinois Department of Corrections, Joliet, Illinois Progressiver more responsible positions within this state corrections agency: Director, Adult Reception and Classification Center, oliet, Illinois. Assistant Warden. Program Services, Stateville Correctional Center. Joliet Clinical Services Supervisor, Stateville Correctional Center, Joliet Left to acce Warden's )osition in Bucks Count Penns lvania. I Philadelphia County Prisons, Program Planning and Evaluation Unit Responsible for the development of rehabilitation and staff training programs, and the evaluation of internal operations. Programs which I personally developed included: Correctional Studies Training Program, Addictive Disease Treatment Program (with Dr. Ed Guy). Developed modi?cations for programs in inmate education, training, work release and recreation. BackgroundInformation Arthur M. Wallenstein - Page4 5/1971 -8/1 972 2/1972-5/1972 9/1967-2/1970 EXPERT WORK INTERNSHIP Planning Analyst, Prison Society - Philadelphia, Developed program recommendations during an evaluation of the internal operations of the Philadelphia County Prison system. Counselor, Fort Benning_Disciplinary Barracks - Columbus, Georgia During my tenure at the US. Army Officers Infantry School, I started a volunteer counseling program for men in custody at the Fort Benning Stockade. The program continued after my departure. Institution, Volunteer Teacher and Caseworker, State Correctional Philadelphia, Volunteer teacher and caseworker. While a graduate student at the University of I participated in a pilot program involving teaching and casework at this maximum-security institution. This was the ?rst introduction of volunteers into this correctional setting. From 1977 through March 2015 when I retired I declined to do formal expert witness or consulting assignments. During that entire period I was a Department Director and Warden and I felt it was a professional conflict of interest to be evaluating the work of others when I was conducting full scale correctional operations myself. This was a matter of personal conscience I received many calls/requests from the federal government and others and declined all requests. After I retired in March, 2015 I report the following: Formal Technical Assistance National Institute of Corrections (NIC) USDOJ for Bernalillo County, New Mexico Albuquerque Bernalillo County Jail and Corrections Use of Force and Training Process Issues. Completed November, 2015 TA 15.11062 (Lead Consultant) National Institute ofCorrections, Washington, DC. Expert Witness - Current and Ongoing, McDonald v. Franklin County, Qh_ig, United States District Court, Southern District of Ohio Eastern Division (Plaintiff), prepared expert witness report case is in process, 2014 -- present. US Department of State, Bureau of African Affairs (Office of Southern African Affairs), 1966-1967, political affairs intern while at Georgetown University. Background Information - MILITARY AWARDS APPOINTMENTS Arthur M. Wallenstein Page 5 1st Lt., US Army Reserve (active duty discharge, May 1972 - reserve period ended - 27 July 1975). Assigned to Ft. Benning, Georgia - Infantry and Military Intelligence. (direct from DD214) Montgomery County Family Justice Center Foundation, Inspiring Leader Award in Public Service, 2014. Bernard Harrison Lifetime Achievement Award in Correctional Health Care, Presented by the National Commission on Correctional Health Care, 2004. ?rst time awarded to a line correctional administrator. Washington Council on Crime and Delinquency, Outstanding Public Employee, 1998. King County - Martin Luther King, Jr., Humanitarian Award, 1996 and 1992. American Jail Association, Howard B. Gill Award - Jail Administrator of the Year (National Award - Large Jails), 1988. Prison Wardens Association, Warden of the Year, 1986. Chair Corrections Committee, Metropolitan Council of Governments (COG) Elected to a second term as Chair of the COG Committee covering all 10 Jurisdictions Maryland, Virginia, Washington, DC and adult corrections/jail operations. National Institute ofCorreetions Advisory Board (US ustiee Department) appointed September, 2010, by Attorney General Eric Holder to a three year term (2010-2013). Previously appointed by Attorney General Janet Reno (1994-2004). Chair, Jail Reentry Advisory Group (2007-2008) national project on Jail Reentry Life after Lockup: Improving Reentry from Jail to Community, conducted by Urban Institute, John Jay College of Criminal Justice and Bureau ofJustiee Assistance. National Association of Counties, Justice and Public Safety Steering Committee Member - October 2000 Present. Background Information - Arthur M. Wallenstein - Pageo PUBLICATIONS Commission on Crime and Delinquency. Commissioner and Member representing Adult Corrections/Jails - October 1979 to August 1990. Statewide criminal justice planning agency with nonpolitical gubernatorial appointment. Chairman, Jail Overcrowding Task Force. Steering Committee, Prison and Jail Overcrowding Committee. Developed and implemented funded program to assist local county correctional facilities. Commission on Crime and Delinquency Southeast Regional Advisory Committee, 1978- 1979 (nonpolitical gubernatorial appointment). Advisory Board, Prison Society. ?Intake and Release in Evolving Jail Practice,? Prison and Jail Administration Practice and Theory, Carlson and Garrett Aspen, Maryland, 2014, pp: 18 - 36; (3rd edition); ?Strategies for Building on What We Know About People with Mental Disorders in the Criminal Justice System, ?Offender Programs Report, Vol. 3, No. 6, March/April, 2000, pp. 85 91. ?Jail Crowding: Bringing the Issue to the Corrections Center Stage,? Corrections Today, December, 1996, pp. 76 81; Wholly False Sense of Security: Wilson v. Seizer and ail Litigation," National Institute ofCorrections mga Jail Report, October 1990. Family Reuni?cation for Khmer on the Thai-Cambodian Border, U.S. Committee for Refugees, Washington, DC. (1988) with Court Robinson. New Prison Planning: Advocacy for a Regional Planning Process, National Institute of Corrections (September 1987) - presented at the American Correctional Association national meeting for the National Institute of Corrections, August 1987. "New Generation/Direct Supervision Correctional Operations," American Jails, Spring 1987. Intergovernmental Aspects of Prison and Jail Overcrowding, Brookings Institute, Washington, DC, December 1986 Presentation. Background Information - Arthur M. Wallenstein Page? A Design and Implementation Process for New Generation Jails - presented to the American Correctional Association National Conference, 1985. "Jail Overcrowding," Prison Joumal, June 1982. "Chillon Castle Revisited," Prison Journal, February 1981 (Part II). "Chillon Castle Revisited,? Prison Journal, February 1980 (Part I) Correctional Law: An Annotated Bibliography - Prison Wardens Association, May 1979. The Operation of a County Furlough Program, presented to the National Conference on Jail Crisis, National Association of Counties, 1978. Co-author: The Dynamics of International Organization - Dorsey Press, Illinois, 1972; 740 pages - Text on international cooperation through various international organizations (United Nations, etc.) PP