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Covid-19 Inspection of the Shelby County Men’s Jail at
201 Poplar Avenue, Memphis TN 38103
Final Report

Submitted to:
The Honorable Sheryl H. Lipman
District Judge
United States District Court
Western District of Tennessee
Western Division

Produced by:
Mike Brady
Director
Sabot Consulting

June 29, 2020

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TABLE OF CONTENTS
INTRODUCTION ................................................................................................. 1 
THE JAIL SETTING............................................................................................. 4 
INSPECTION OBSERVATIONS - JUNE 23, 24, 25, 2020...................................... 5 
COVID-19 SCREENING FOR EMPLOYEES ....................................................... 6 
INTAKE/BOOKING/RELEASE............................................................................ 8 
MEDICAL ........................................................................................................... 10 
MENTAL HEALTH ............................................................................................ 11 
MEDICAL ISOLATION LOWER LEVEL PODS A-K........................................ 13 
FLOORS 1-6........................................................................................................ 15 
POPULATION MANAGEMENT ........................................................................ 17 
STAFFING SHORTAGES................................................................................... 18 
FINDINGS AND RECOMMENDATIONS .......................................................... 19 
CONCLUSION .................................................................................................... 27 
EXHIBIT 1 – INSPECTION ORDER .................................................................. 30 

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INTRODUCTION
My name is Michael K. Brady, and I am the Director of the Criminal Justice Division for
Sabot Consulting. I am a nationally recognized expert in prison and jail operations, the
Americans With Disabilities Act, and the prevention and mitigation of the spread of
infectious diseases and public health in the correctional setting from an operational and
non-clinical perspective.
On June 18, 2020, in the matter of Busby V Bonner ( No. 2:20-cv-2359-SHL), pursuant
to Federal Rule of Evidence 706, United States District Judge For The Western District
of Tennessee, Western Division, The Honorable Sheryl H. Lippman, appointed me as the
neutral expert witness in the field of jail and prison operations as it relates to the
prevention and mitigation of the spread of infectious diseases and public health in the
correctional setting.
The Inspection Order states in pertinent part:
“…The appointed expert shall provide information to the Court responsive
to Plaintiffs’ Motion for Temporary Restraining Order (ECF No. 2) and
render an expert opinion on the current health and safety of medicallyvulnerable Plaintiff-detainees at the Shelby County Jail (“the jail”) in light of
the Covd-19 pandemic, including but not limited to the Facility’s compliance
with the pertinent CDC and Shelby County Public Health guidelines and
other applicable standards. The expert’s findings shall include, if warranted,
recommendations regarding corrective measures that, in his expert opinion,
should be implemented at the jail, to protect the medically-vulnerable from
the COVID-19 virus at the facility….” (See Inspection Order Filed On June
18, 2020, attached as Exhibit 1)
The medically-vulnerable detainees to which the inspection order applies are defined as
follows:
1. People 65 years and older
2. People with chronic lung disease or moderate to severe asthma (including
chronic obstructive pulmonary disease (COPD) (including emphysema, and
chronic bronchitis),
3. Idiopathic pulmonary fibrosis and cystic fibrosis;
4. People who have serious heart conditions (including heart failure, coronary
heart disease, congenital heart disease, cardiomyopathies, and pulmonary
hypertension);
5. People who are immunocompromised (including cancer treatment, smoking,
bone marrow or organ transplantation, immune deficiencies, poorly controlled
HIV or AIDS, and prolonged use of corticosteroids and other immune
weakening medications);
6. People with severe obesity (body mass index [BMI] of 40 or higher);
7. People with Diabetes;
8. People with chronic kidney disease undergoing dialysis;
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9. People with chronic liver disease, including cirrhosis; and
10. People with hemoglobin disorders, including sickle cell disease and
thalassemia.
11. All persons currently or in the future held at the jail in pretrial custody during
the COVID-19 pandemic who are at increased risk of Covid-19 complications
or death because of disabilities as defined in the Americans With Disabilities
Act (ADA) and Section 504 of the Rehabilitation Act.
In order to have a better understanding of the contested facts of this case, I read the
pleadings and declarations submitted by both Petitioner-Plaintiffs and RespondentDefendants.
In addition, I requested relevant documents from Petitioner-Plaintiffs’ Counsel,
Respondent-Defense Counsel, and Wellpath’s Counsel in advance of my unannounced
arrival at the Shelby County Pre-Detention Jail located at 201 Poplar Avenue, Memphis,
Tennessee, 38103.
In addition from 0830hrs until approximately 2300hrs for three consecutive days, I
conducted multiple in depth interviews with key personnel for the Shelby County Jail,
key personnel with the contract medical provider, WELLPATH , walked the decks on
each floor of the jail, inspected each of the living units, dayrooms, common areas,
showers, toilets, medical clinic, intake/booking/release, interviewed staff and inmates on
the first (0600-1400hrs) and second watch (1400hrs-2200hrs), inspected the holding cells,
the court tunnel, the upstairs court holding cells, transportation vehicles, and from the
control center on the lower level observed inmates being escorted through the court
tunnel, placed in the holding cells, escorted upstairs to and from the General Sessions
Court and Criminal Courts, and back to through the tunnel toward their living units.
I was very fortunate to have newly promoted Lieutenant Styles as my security escort and
guide. She is intimately familiar with all aspects of the Shelby County Jail operations and
was responsible for the seamless scheduling of staff and inmate interviews, escorting me
through any and all parts of the jail, gathering not only the documents I requested in
advance, but additional documents that I needed as a result of my interviews and
observations throughout my three days of inspection. She was my security escort,
scheduler, facilitator, problem solver, and reservoir of knowledge, from 0830 to 2300hrs
every day of the three long days of my onsite inspection. We continue to communicate as
needed this weekend for any additional documents I may need or questions I need
answered as I pen this report. Without her assistance, it would have been impossible for
me to have achieved the in depth understanding of all aspects of the Shelby County Jail
Operations necessary to compete this inspection report. Thank you Lt. Styles.
I also want to acknowledge the Chief Fields, Assistant Chief Hubbard, Assistant Chief
Ward, Dr. Bruce Randolph, Dr. Judy Martin, Dr. Donna Randolph, Jeremy Sanders, Ms.
Geeter, Mischelle Best, and all their respective staff for allowing me to repeatedly take
time away from their busy schedules to answer my questions and provide me with the
documents I needed to verify the policies, procedures and practices about which they

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spoke were in writing. They are consummate professionals who care deeply about the
inmates in the Shelby County Jail.
At all times of the day or night, I had unrestricted access to key personnel and the jail
facility. Shelby County Jail command staff and Wellpath leadership were transparent,
responsive and open to new approaches in addressing the opportunities for improvement
that I discovered during my court ordered inspection.
It is important to remember that during the course of my inspection, it was necessary for
me to explore potential solutions to each area of concern I identified during my
inspection. Recommending corrective measures to the Court that are not practical or
doable would render my recommendations useless, a prolific waste of time, energy, and
money. It was not my intent to usurp the authority of the Court or the interest of the
parties in exploring those options, but rather to find meaningful, efficient, cost effective,
and practical solutions to preventing and mitigating the spread of this highly contagious
and oftentimes deadly virus among the vulnerable population housed in the Shelby
County Jail.

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THE JAIL SETTING
County Jail operations have many unique characteristics:
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Jails operate continuously, 24 hours per day, 365 days per year.
Jails provide a wide spectrum of services, activities, and programs for inmates.
Jails are high-risk settings where inmates are often dangerous to themselves and
others.
Jail populations have a significant percentage of inmates with chronic diseases
serious medical conditions, serious mental illness, and disabilities
Jail populations can fluctuate widely throughout the year, and even on a day-to
day basis.
Many jail inmates spend only a few hours in jail or a few days especially in light
of the new bail statutes, pretrial release programs, and other court actions.
Many other inmates remain in jail for months or years because of the serious
nature of their charges or their inability to make even the lowest bail amount.
Admission and release procedures require much staff effort, but the peak periods
of admission are often difficult to anticipate (special events, parole/probation
sweeps, gang sweeps, homeless camp sweeps, demonstrations, DUI checkpoints,
etc.).
Extensive Documentation is required for all activities and procedures at the jail.
Perimeter security and internal movement must be controlled at all times.
Supervision needs vary for different classifications of inmates.
Jail staff, administrators, and funding officials can be held liable for
substandard/constitutional deficient jail operations and conditions.
Transportation to and from outside medical appointments, inpatient
hospitalizations are difficult to anticipate and staff.
Jails now are one of the largest and most challenging mental health treatment
facilities in the country.
The provision of quality medical care to an older, sicker, inmate population is
incredibly expensive and challenging.

In recent years, recruiting and maintaining adequate badge staff has been extremely
difficult and current events have exacerbated the problem. Many jails are short staffed
and have to employ robust mandatory overtime initiatives that are unsustainable.
Couple these challenges with the current attempts to limit the spread of the highly
contagious and deadly Covid-19 virus in the Shelby County Men’s Pre-Detention Facility
(hereinafter “the jail”), and it becomes exponentially more difficult.

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INSPECTION OBSERVATIONS - JUNE 23, 24, 25, 2020
It goes without saying that these are extraordinarily difficult and dangerous times in
which we find ourselves thrust today. Operating a large county jail such as the Shelby
County Jail is challenging, complex, and labor intensive.
Attempting to prevent/mitigate/eradicate the Covid19 virus within the secure perimeter of
the jail, adds an additional daunting and extraordinarily labor intensive layer of
multidisciplinary work that must be implemented with precision, armed with the
flexibility to adapt to new discoveries, guidance and directives from the CDC and Public
Health in real time, and be monitored with hypervigilance to ensure its effectiveness.
As you can imagine, each county jail is unique and there is not a single Covid-19
operational response model that is effective for all jails. The core principals of social
distancing, testing, tracing, and isolation must be present, but how those four core
principals are implemented are oftentimes restricted because of the physical plant,
population size, and staffing. Shelby County is no different.
On Tuesday morning, June 23, 2020 at approximately 0730hrs, I notified my security
escort, Lt. Styles that I would be conducting my inspection of the Shelby County Jail and
that I would be arriving at the Shelby County Detention Facility at 0830. The date and
time of my inspection was unannounced until one hour prior to my arrival. Lt. Styles met
me at a secure parking lot off Washington Street and we entered the jail through the
employee entrance. I was wearing a surgical mask, and Lt. Styles was wearing a mask as
well.

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COVID-19 SCREENING FOR EMPLOYEES
Immediately upon entering the jail outside the secure perimeter, there was an
employee/contractor screening table. I was asked to fill out a “Coronavirus Screening”
questionnaire which posed the following questions:
1. In the past 14 days, have you been outside of the United States and/or, on a
cruise or been in contact with anyone who has? Yes_ No_ If so, When___
Where___
2. In the past 14 days have you been in crowded areas, (for example Airports,
Conferences, Concerts, etc.) YES__NO__ If so, When__ Where__
3. Have you or anyone you have had close contact with been diagnosed with or
quarantined for Coronavirus? (The incubation period is 2-14 days)
YES__NO__
4. Do you have a fever, cough, difficulty breathing, diarrhea, headache, loss of
taste or smell or symptoms of lower or upper respiratory illness? YES__
NO__
My temperature was taken and recorded on the questionnaire.
At the bottom of the questionnaire, the final statement was “If answered yes to any of the
questions above, please see the immediate Supervisor of the area.”
The Supervisor of the area cleared me for entry into the secure perimeter of the jail.
While in the employee screening area, I paused and observed several employees enter the
facility through that entrance and all were wearing face masks, filled out the
questionnaire and had their temperatures taken. I was provided with the temperature logs
from the employee screening area for the last 90 days.
This is the process that was followed each day that I entered the facility at 0830hrs. On
days two and three, I was not escorted by Lt. Styles, but I followed the same routine. Lt.
Styles was already on the premises and came out from the secure perimeter to get me
each morning and evening on days two and three.
Each day of my inspection, I paused in the employee screening area to observe
employees entering the jail. 99.9 percent of the employees who entered the area were
properly wearing their masks, had their temperature taken and filled out the questionnaire.
On day two of my Inspection, I observed two men in street clothes enter the screening
area who were not wearing masks, did not practice social distancing, and were not issued
masks prior to going in to the secure perimeter of the facility. The security officer in
charge of the secondary screening area did not stop them from entering the facility with
no masks.
Once inside the secure perimeter of the building, I met with Chief Jailer Fields, and
Assistant Chief of Security Hubbard to get a better sense of how their jail operated on a
day to day basis, and to discuss some of the challenges they faced from their perspective
in combating the spread of the Coronavirus in their facility. I found both Chief Fields and
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Assistant Chief Hubbard to be welcoming, transparent, cooperative, and openminded. I
was presented with two binders of documents that I had previously requested responsive
to items 1-15 in the Inspection Order signed by Judge Lipman. At the conclusion of this
report I will list the documents that I reviewed as part of this Inspection.
We were then joined by Dr. Judy C. Martin, PhD, NP-BC, Chief of Nursing for the
Shelby County Health Department, and Jeremy R. Sanders, MPA, the Health Services
Administrator for Wellpath for the Shelby County Jail. I spoke with them and let them
know how I intended to conduct my inspection over the next several days.
After I met with the Jail Command Staff, I ask to see the entire jail facility from an
inmate’s arrival through the Sally Port through release. Over the course of the next
several days, I would meet with and ask questions of a variety of key jail personnel,
Shelby County Health leadership, and Wellpath leadership as well as inspect all parts of
the jail in which vulnerable inmates and inmates with disabilities were housed, held or
moved to and from (medical, mental health appointments, pill call, and court)
Dr. Martin and Mr. Sanders wished to accompany me on the first day, and I welcomed
them because I wanted them to see what I saw in real time, and it was more efficient to
have healthcare leadership present to answer any healthcare related questions about
which Lt. Styles might not be intimately familiar.

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INTAKE/BOOKING/RELEASE
I began my inspection in the Intake/Booking area and the sally port where all law
enforcement are required to bring arrestees for screening and booking.
24 hours a day, 7 days a week, 365 days a year all arresting agencies who enter the sally
port are required to keep the inmate in the agency vehicle until it is there turn to present
the arrestee for a pre-booking Covid19 healthcare screening. They are asked a series of
healthcare questions about any symptoms that they may be experiencing related to
Covid19 and they are administered a temperature strip which is then passed back through
a glass barrier to the nurse on the other side.
If the inmate is asymptomatic, they are issued a mask and placed in a holding cell inside
the secure perimeter and they go through the normal booking process. The inmate is
searched, photographed, fingerprinted, and interviewed by pretrial services. Pretrial
Services administers a new Public Safety Assessment tool along with the old assessment
questionnaire to determine if the inmate is eligible for release on his or her own
recognizance (ROR) or if he or she will have a bond set by the Commissioner. The bond
is set within the first 24 hours.
If they are not eligible for ROR, the inmate will be dressed out, processed through
classification and housed in a general population isolation unit that is cohorted for 21
days. (Lower Level A-G)
If the inmate is symptomatic, the inmate is escorted immediately over to a tent area on
the far end of the Sally Port, and healthcare staff and security staff come out in full
hazmat PPE and conduct a more in depth healthcare screening to determine if the arrestee
is suitable for confinement (Not in acute respiratory distress or suffering from some other
medical condition that requires the inmate to be transferred to the ER at Region1
Medical). If the inmate is suitable for confinement, the inmate is placed in full PPE
including a hazmat jumpsuit, booties, facemask and eye protection and escorted to a
medical quarantine area where he will remain for 21 days. Inmate is tested immediately
with the nasal pharyngeal test for Covid19. The positive inmates’ temperatures are taken
daily, for 21 days, but no other Covid19 tests are performed. Wellpath uses a non-test
based strategy for asymptomatic and symptomatic inmates. Inmates must remain in
medical isolation for 21 days prior to being released to general population.
If an inmate is symptomatic, his clothing is placed in a hazmat bag and disposed of as
hazardous material.
During the course of my inspection and multiple observations of the booking area, I
witnessed an inmate being booked into the jail who was not wearing a mask and the
arresting officer had his mask down below his nose. The inmate was allowed to enter the
interior of the booking area without a mask and was placed in a holding cell. The inmate
was without a mask for a significant portion of the booking process. Lt. Styles was
present when I made this observation.

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Moreover, we observed at least one officer with his mask down around his chin when he
entered the booking area, and, on another occasion, down below his nose.
Episodic violations of the health screening process, and the mask policy for inmates and
staff creates an undue risk of harm to the vulnerable inmates who are processed through
the booking area.
I also inquired about the cleaning process for the intake/booking area and it was learned
that while the common areas and phone banks are cleaned every hour, the holding cells
are only cleaned at the beginning of the shift and one or two additional times. This
practice while important, is insufficient to protect subsequent vulnerable inmates from an
unreasonable risk of exposure to the virus as a result of a potentially asymptomatic
positive inmate contaminating the hard surfaces in the holding cells, the phones, the
toilets in the holding cells (we know that there have been at least two studies that suggest
that the virus can be shed through stool and urine but further studies are needed). I do
want to note that this jail would be considered very clean in normal times. The floors are
polished, the walls are clean, the empty cells are free of debris, human waste, and the
toilets appear to be clean. It is obvious that the Command Staff go to great lengths to
keep this older jail clean.

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MEDICAL
The next area I inspected was the medical clinic area. There is no Outpatient Housing
Unit or Infirmary in the jail. Anyone requiring those services must be transported to an
outside facility. The Wellpath staff conduct regular sick call and during this time of crisis
use Telemedicine for much of their Physician appointments. I observed the clinic area
and spoke with several nurses. The area was clean and I observed inmates being seen in
the clinic and via telemedicine including on HIV patient communicating with his
physician via telemedicine. All participants were wearing appropriate PPE and were
properly social distancing. I note that during the course of my three-day inspection, I did
notice episodic violations of the mask policy by healthcare workers.
I also observed pill call on the housing units and noticed that there we newly installed
markers for social distancing along the corridor where pill call is conducted. The inmates
on the occasion of my inspection were properly social distanced and were wearing masks.
While I observed some episodic violations of the mask policy by inmates having their
masks down below their nose, staff was quick to direct the inmate to put the mask over
their nose. In each case, the inmate complied.
When asked about outside specialty appointments for Chronic Diseases and Serious
Medical Conditions, Wellpath’s Medical Director, Dr. Donna Randolph told me that
Region1health were not accepting appointments from the jail for several months during
the Covid19 pandemic, but they have recently started accepting appointments again. She
stated that it is still a challenge to get inmates in need of specialty care regular
appointments because Region1health only accepts appointments for inmates one day a
week and that single day must accommodate inmates from the Shelby County Penal Farm
and the Federal Detention Facility located in Shelby County. There is a dialysis clinic
that occurs at the jail regularly and the dialysis patients have not experienced any delays
in their care. I spent a considerable amount of time with Dr. Randolph and Mr. Sanders
and I found them to be well informed and passionate about delivering competent medical
care to the inmate population. The care that is delivered by Wellpath is hampered by
reliance on resources they cannot control and as a result inadequate chronic care and
specialty care may be occurring.

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MENTAL HEALTH
There is a housing unit for inmates who are suicidal and are on fifteen-minute checks.
However, if any behavioral health inmate would be in need of more intensive care, they
would have to be transported to an outside hospital. One practice that concerns me for
this vulnerable population is that all inmates on 15-minute checks are issued suicide
resistant smocks rather than following the best practice of evaluating the need for a
smock on a case by case basis. The blanket policy of issuing smocks to everyone will
discourage some inmates from revealing their suicidality because they don’t want
everything taken from them and to be stuck in a smock. Inmates view this as punitive. I
spoke with the Mental Health Director Ms. Geeter regarding this issue. The SMI
population is part of the vulnerable population as disabled inmates. This population more
often than not has co-morbid medical conditions that require monitoring and treatment.
Dr. Randolph and Ms. Geeter assured me that the SMI population are getting their labs
done in a timely fashion (as I understand it some of the psychotropic medications can
cause liver and kidney problems as well as significant weight gain) Wellpath has
contracted with Lindsay Hayes, a nationally recognized expert on Suicide Prevention,
and Mr. Hayes was scheduled to return to the jail for a follow up visit, but because of the
Covid19 he has been unable to return to the jail.
I was pleased to observe several suicide resistant cells in this unit. These cells have
eliminated the tie off points that are commonly used by inmates who are attempting to
commit suicide. 90% of the suicides that take place in a jail setting are by hanging. The
Mental Health Director, Ms. Geeter, personally trains security staff and non-security staff
on suicide prevention practices. Ms. Geeter also uses Lindsay Hayes’s suicide prevention
manual and curriculum. The initial training is between six to eight hours (depending on
the number of questions asked during the session) and the refresher training is two hours.
Wellpath does not have a formal structure to their mental health delivery system, but
Wellpath does employ one full time Psychiatrist, one half time Psychiatrist, several
LMSWs, LPCs, LSWs, and one Psychiatric NP.
There are about 200 behavioral health inmates on the second floor, and there are
approximately 150 more higher functioning behavioral health inmates scattered
throughout the jail. Many of those inmates are on medication management only, but Ms.
Geeter’s team does not have a formal treatment program structure, but does deliver basic
mental health services, special needs services, individual therapy, and crisis management
and assessment.
One concern that I have is that Wellpath does not employ a Clinical Psychologist to
formally test for Developmental Disabilities(DD) and Learning Disabilities(LD). The DD
population who are in need of higher adaptive support are subject to victimization (sexual
assault, other inmates stealing their commissary, carry drugs and weapons for gangs) and
have short term memory problems, difficulty understanding directions, forgetting to
shower, wash their hands, clean their cells, eat, etc. Ms. Geeter told me that anyone who
is suspected of being DD is seen by a psychiatrist. The DD population can be as large as

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two to four percent of the inmate population (38-76 inmates) with a much smaller number
being profoundly DD requiring high adaptive supports and protection from victimization.
There is no formal testing that occurs for the LD population. Learning Disabled inmates
do not want people to know that they cannot read, write, or have trouble understanding
words, sentences and documents with which all of us may not struggle. It is important
that effective communication is used with this population and that means using simpler
words, talking slower, explaining the Covid19 education materials to them, etc. Equally
important for them to have equal access to the programs, services, and activities in the
jail, Wellpath must screen for and identify this population to make sure that security staff
and program staff are effectively communicating with them, that they understand the
Covid19 education materials and that they rules and regulations of the jail. The LD
population while not medically vulnerable, they are disabled as defined by the ADA, and
are entitled to accommodations for their disabilities.
I spoke with Ms. Jackson who oversees the crisis unit where suicidal patients are housed.
She is very passionate about her job and has a very good relationship with the inmates in
her unit. The time constraints around this inspection prevented me from spending more
time with her and learning more about her unit.
Ms. Geeter and Ms. Jackson clearly care about this very vulnerable population and do
their best to ensure the inmates in the Behavioral Health Delivery System are properly
treated.
My next area of inspection was the housing units themselves. Lt. Styles, Dr. Martin, Mr.
Sanders and went to all the living units together on the first day, and then Lt. Styles and I
went back to the living units to interview inmates from the list of vulnerable inmates and
inmates with disabilities the following two days. The vulnerable inmates/ADA inmates
who are the subject of this Court ordered inspection are scattered throughout the jail in all
security levels on all floors.

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MEDICAL ISOLATION LOWER LEVEL PODS A-K
In their Covid-19 response policies, procedures and practices, Wellpath and the jail
represent that asymptomatic newly incarcerated inmates are medically isolated for 21
days and then released to general population living units commensurate with their
security level.
However, I was told by several inmates that I interviewed that these newly incarcerated
inmates do not remain in medical isolation from the rest of the population for 21 days as
the Covid-19 response policy and booking flow chart represents.
Allegedly, throughout the 21 days the inmates are intended to be isolated from the rest of
the jail population in order to prevent the introduction of the Covid-19 virus into the jail,
they are required to be moved from their isolation units through the court tunnel and into
holding cells for the General Sessions Courts and the Criminal Courts of Shelby County.
The medically isolated inmates are mixed in the Division specific holding cells with 2025 other general population inmates from throughout the jail for up to 4 hours. This
occurs in the morning and afternoon multiple times a week. Most of the time, according
to the inmates I interviewed, the inmates do not leave the holding cell or they are directed
to walk up the stairs to the court hallway where they are handed a piece of paper and told
their case has been reset for another date. The inmates then walk back down the stairs
back through the court tunnel returning to their living units in the jail and the medical
isolation units on the lower level.
In order to determine that this was actually occurring, during court hours, I went to the
control booth in the lower level that keeps the court tunnel, the lower level holding cells,
and the stairs to the courtrooms under constant camera surveillance. While in that control
booth with Lt. Styles and the control booth security officer, I could see the constant
inmate movement through the court tunnel to and from the holding cells. In the holding
cells there were approximately 20-25 inmates in one, 16 in another, and 6 in another. I
observed some inmates were not wearing their masks. I observed inmates walking up and
down the stairs to the courtrooms. I saw that there was no social distancing in two of the
three holding cells. I observed some security staff were not properly wearing their masks
in the tunnel.
Once I verified this practice, I circled back and spoke with Chief Fields, Assistant Chief
Hubbard, Dr. Donna Randolph, and Mr. Jeremy Sanders. All verified that this was taking
place shared my concern about the practice, but felt they had no control over how the
court handles their calendar and appearances.
This practice unquestionably puts vulnerable inmates and the ADA inmates at an
unreasonable risk of harm from potential expose to asymptomatic Covid-19 positive
inmates. Without an immediate change to this practice, it clearly renders any attempts to
medically isolate asymptomatic newly incarcerated inmates from the rest of the jail
population ineffective and of little value. The risk of infecting other inmates and
introducing the Covid-19 virus into the general population of the jail is high.

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It should be noted that on the lower level there are two holding cells that have video
hearing capability for the courts. Those holding areas are LLR and LLS.

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FLOORS 1-6
While the pleadings and declarations I read in preparation for my inspection imply that
nothing special is done for the vulnerable inmate population. During my inspection, I
became aware that medical does have several small living units on the 2nd floor where
they house medically fragile inmates (2B-2E, 2J, 2K, 2L). These inmates are medically
fragile/ vulnerable inmates who need more intensive observation and treatment. The
medical offices are on this floor. The ingress and egress to this unit is controlled, and
medical has to approve anyone who is to be housed in this area. This area has a limited
number of beds and currently is at capacity. During the course of my inmate interviews
on this floor, several inmates complained that social distancing is not possible and that
the living area, showers, and bathroom was dirty. After my interview with the inmates
which occurred outside the living area for privacy reasons, I went into the living unit with
Lt. Styles and we inspected the area for cleanliness. Lt. Styles and I both observed the
living area and the bathroom to be in need of cleaning. Lt. Styles immediately directed
staff to clean that living unit and bathroom. It is the policy of the jail that all inmates must
wear masks and for the most part they were wearing masks, but some did not have masks
on or they had the mask down below their nose. Individuals with COPD who have
difficulty breathing are going to resist wearing these masks all the time because they
restrict their breathing even further.
The third-floor houses Level 7 inmates and some Level 5 and 6 inmates. Given the
current population levels in these units, it is not currently possible to property social
distance under the current program structure. Most of the Pods have 35-38 inmates in a
Pod with a capacity of 43.
The jail’s current policy directive is that all inmates are to receive free soap and that soap
is not to be confiscated if the inmates have more than one bar. The vulnerable inmates
that I interviewed complained that if they have money on their books, the housing
officers will not allow them to have free soap. The inmates complained that it is not
possible to social distance because the dayroom is crowded with 20 or so inmates at a
time. In one of my multiple interviews with Chief Fields across several days, I asked him
about this and he told me that they inmates can have free soap by policy. I also noted that
in these living units, there were hand sanitizer dispensers installed on the walls, but the
inmates told me they could not access the hand sanitizer because it is behind the officer’s
desk which is out of bounds for inmates. The inmates did verify that recently there has
been an increased effort to clean the living units more frequently. During my three days
of inspection, I did observe a cleaning crew under the direction of Mr. Dwayne Johnson
with biovex sprayers on their backs cleaning common areas throughout the jail. The
inmates stated they were given cleaning supplies but the mops they were given to clean
their cells were mops that everybody else had just used to clean their cells and they were
concerned about cross contamination.
The fourth-floor houses Level 8 and 9 inmates, high profile inmates, overflow suicide
watch, and two program pods. These living units are at or near capacity making social
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distancing impossible under the current dayroom use policy. At least twenty inmates are
out in the dayroom area together during dayroom time, and the tables only seat 4 inmates.
Throughout my inspection tour I observed inmates out in the dayroom and although 99
percent were wearing masks, there just is insufficient room to properly social distance.
The vulnerable inmates that I interviewed had similar complaints regarding free soap, and
social distancing. The inmates did acknowledge the stepped-up cleaning of the common
areas in the last several weeks. The hand sanitizer dispensers were located behind the
security officer’s desk and in an area that is out of bounds for inmates.
The fifth floor is a dormitory floor consisting of three units of 32 bunks totaling 64 beds
each. 5A houses inmates with security levels of 1-5. 5B is a program dorm of 32 bunks
totaling 64 beds. 5C houses security levels 5-6 and has 32 bunks totaling 64 beds. Each of
these dormitories were not at capacity. It appeared they were at about 50 – 60 percent of
capacity. There was some social distancing in these units but there were two to a bunk,
and the occupied bunks did not always have a vacant bunk in between them. The
vulnerable inmates I interviewed in these units had similar complaints regarding the
availability of free soap, social distancing, and cleaning supplies. The living units
appeared to be clean. The inmates acknowledge a recent increase in the frequency of the
cleaning of the common areas. The inmates told me that the jail had just put in the social
distancing markers in the pill call line and on the floors of the living units just last week. I
observed the inmates wearing their masks but not universally. The some of the inmates
on all floors complained about their masks falling apart. They acknowledged that the jail
cleaning crews offered to disinfect their masks with the disinfectant, but they did not
want them to do it because of the chemical smell and it takes a while for the mask to dry.
The sixth floor is a dormitory floor that consists of 3 living units of 32 bunks and 64 beds.
It is currently empty. This area can house inmates who have security levels from 1-7.

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POPULATION MANAGEMENT
As of June 29, 2020, the inmate population of the Shelby County Jail is 1854 inmates.
The jail has a capacity of 2600. The jail currently books 38 inmates a day on average and
releases 24 inmates a day on average. The jail is an older jail that was built in the 1980’s
and as a result, most of the cell doors are open bars are the top and are operated
electronically via a control panel and Folger keys. Approximately 8 different law
enforcement departments within Shelby County book arrestees in the jail. Additionally,
surrounding counties will request that the jail take some of their inmates when they reach
capacity. The jail also currently houses Tennessee Department of Correction inmates who
come back to Shelby County for court matters.
Reducing the population of the jail in these unprecedented times is a challenge. The jail
as a matter of law cannot refuse to book an arrestee who is medically fit for incarceration
nor does the Sheriff have the authority to release inmates to alternative forms of custody
such as active GPS, supportive housing in the community, shelters, recovery homes,
home detention, work release, etc. The authority to do that rests solely with the Shelby
County Court. Currently the jail has a case expeditor to try and move cases along, but
from my observations during my inspection the current practice of the Shelby County
Courts and the attorneys representing the inmates is creating a significant backlog that is
contributing to the size of the jail population. Cases are being postponed multiple times
for lengthy periods of times allegedly without the consent or time waiver of the inmates.
The inmates are not being provided their discovery packets until months after their arrest
and detention. Attorneys are not visiting their clients and discussing their cases. Offers
are not being made in an effort to resolve cases. The vulnerable inmates that I
interviewed during my inspection complained about the lack of information. The failure
of their defense attorneys to visit them. The failure of their attorneys to consult with them
regarding waiving their constitutional right to a speedy trial. The court allegedly is
refusing to release inmates who are committed non-violent crimes and are not a current
threat to public safety. Defense attorneys are allegedly failing to present medical
evidence of their client’s serious medical condition to the court that would demonstrate
the inmate is not currently a threat to public safety or to argue for placement in alternative
forms of custody. They cannot present the evidence because they allegedly are not
meeting with their clients and gathering the necessary evidence to present to the court.
In addition, the Tennessee Department of Correction is not accepting inmates who have
been convicted and sentenced to prison. The jail houses state prison inmates who are
back from prison to resolve some outstanding court matters.
Moreover, towns in Shelby county bring inmates to the jail when their jail reach capacity,
and surrounding counties also bring inmates to the jail when their jails are allegedly at
capacity.
As a result, the population continues to remain in the mid eighteen-hundreds with little
room to enforce social distancing within the living units in the jail.

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STAFFING SHORTAGES
Currently the jail has 157 security staff vacancies and the Sheriff’s Department is
experiencing difficulty in their recruitment efforts to fill those vacancies. In addition, a
recent staffing study that was completed found that the actual need for security staff is
over 300 positions. Having significant staffing shortages like these is a contributing
factor to consistently providing routine service to the vulnerable inmates in the jail.

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FINDINGS AND RECOMMENDATIONS
These findings and recommendations are not in order of importance.
FINDING #1
The Wellpath Covid-19 response plan is inadequate to protect the vulnerable inmates
housed in the Shelby County Jail for the following reasons:
1. The newly booked inmate movement from medical isolation to the General
Session and Criminal Courts and then back to the medical isolation unit
completely undermines the integrity and purpose of the 21-day medical isolation
that is designed to prevent the introduction of the Covid-19 virus into the jail
population. The medically isolated Inmates are held in holding tanks in large
groups with general population inmates for long periods of time (2-4 hours)
multiple times in the 21-day isolation period. The medically isolated inmates are
not tested at any time during their 21 day stay if they remain asymptomatic, nor
are the inmates from general population who were already housed in the jail, but
who have been exposed to a potentially positive asymptomatic inmate from
medical isolation in the court holding tanks. This presents an unreasonable risk of
harm to the medically vulnerable inmates who are held in the holding tanks with
the asymptomatic medically isolated inmates.
2. Through no fault of Wellpath, their timed out non-testing strategy designed to
prevent the spread of the Covid-19 virus in the jail, is rendered ineffective and
useless as a result of the Court’s insistence on the presence of the medically
isolated inmates in court or near court during the newly booked inmate’s 21 day
medical isolation.
3. The jail does not cluster the vulnerable inmates in housing units together away
from the general population. Wellpath does attempt to cluster the most medically
fragile and vulnerable inmates in the medical area on the second floor, but the
space is limited and the number of vulnerable inmates who are considered to be in
a high-risk group is around 300 inmates.
RECOMMENDATION #1
1. It is recommended that Wellpath move to 14-day medical isolation with a nasal
pharyngeal test-based strategy for symptomatic and asymptomatic inmates who
are newly booked in the jail. The tests should occur between day 3 and day 6 for
the initial test, and between day 10 and day 12 for the second test. All inmates in
medical isolation must be asymptomatic for two consecutive days subsequent to

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the final test results being received before they can be released to general
population.
2. It is recommended that Wellpath and the jail command staff identify living units
where the vulnerable population can be sequestered away from the rest of the
general population inmates without losing their privileges or dayroom time
consistent with their security level. The most medically fragile inmates and the
inmates that are at the highest risk of serious illness or death if they contract the
Covid-19 virus should be housed near the medical unit in case there is a white
alarm. Areas that could be considered are the third floor and the Annex. Custody
might be able to open the sixth floor living units which have 192 beds for the
Level 7 inmates currently housed on the 3rd floor, and move some 3rd floor
inmates from the third floor to the empty cells in the Annex.
FINDING #2
1. Wellpath and the jail command staff have no authority to compel the court to
discontinue the practice of insisting on inmate’s personal appearances in, at, or
around the General Sessions Court or Criminal Court for initial appearances or to
have their matters set over to another date. This practice increases the risk of
inmate exposure and court personnel to Covid-19 infection because of the
clustering of inmates in large holding cells and personal court appearances.
RECOMMENDATION #2
1. Consult with Dr. Bruce Randolph, Shelby County Health Officer, to see if he
would be amenable to adding detention facilities to Shelby County Health
Directive #7 or issuing a separate health directive for detention facilities in Shelby
County. The language in the directive could read that “Any person detained in a
detention facility should be isolated from the rest of the inmate population for 14
days if they are not eligible for ROR and cannot make bond. If the detained
person is eligible for ROR or can make bond, they should be provided with a copy
of Shelby County Health Directive #7 dated June 22, 2020 and instructed to
follow that directive upon release. Nothing in this directive is intended to delay or
impede the release of detained individuals if they are eligible to be released”. This
is in the best interest of public health, and detained people are members of the
Shelby County community and should be protected from unreasonable risks of
infection just like non-detained persons in Shelby County.
2. Consult with the General Sessions Court and Criminal Court and ask the Judges
to use the existing video technology located in holding tanks LLR and LLS for
arraignments, bond hearings, and other court proceedings that would not violate
the inmate’s 5th or 6th amendment rights. In March, the Tennessee State Supreme
Court issued an emergency order suspending in person court appearances for two
weeks, but I am unaware of the validity of this order today. Technology such a
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Skype, Zoom, Microsoft Team, Webex are also available and could be deployed
in a cost effective and efficient manner while limiting the exposure of vulnerable
inmates to infection. Ms. Best, the Sheriff’s Office Expeditor, is a former Judge
and an attorney and could be very helpful in explaining the risk of spreading the
Covd-19 virus among the inmate population if court continues to demand the
inmates appear in, at or near the Courts in large holding tanks. The use of video
arraignments, bond hearings, and other appearances would go a long way in
reducing the risk of vulnerable inmates getting infected with the Covid-19 virus.
3. Wellpath leadership needs to be more aggressive and more vocal about protecting
the vulnerable inmates in their care. There are several practices that take place in
the jail that are potentially harmful to their patients, and they should not be
allowed to continue. I recognize that Wellpath leadership feels powerless to insist
that those harmful practices be discontinued, but in my expert opinion, Wellpath
should have brought those harmful practices, at a minimum, to the attention of Dr.
Bruce Randolph and documented that those harmful practices were brought to the
attention of whatever entity they notified including the Court. Judges can be
dismissive, but it is the responsibility of the medical provider to protect the health
of the inmates in their charge and to speak up and advocate for the safety of their
patients. I know this is an uncomfortable recommendation, but it is the right thing
to do. Doing the right thing is not always easy, but it is always the right thing to
do.
FINDING #3
1. The Shelby County Jail is not maximizing its efforts to enforce social distancing
in its living units and should consider rethinking how it programs inmates in all
areas of the jail.
RECOMMENDATION #3
1. Jail Command Staff could consider allowing fewer inmates in the dayroom area at
the same time. By reducing the number of inmates in the dayroom at one time
while continuing to enforce the mandatory mask order for staff and inmates who
are in the dayroom, the risk of infecting others with the Covid-19 virus will be
reduced. As an example, only allowing 6-8 inmates out in the dayroom at the
same time on the 3rd, 4th, 5th, and 6th floors vs allowing 20 inmates out in the
dayroom at the same time will substantially reduce the risk of person to person
infection. In the dormitory living units, staff can put some inmates on bunk status
until it is time for them to program in the dayroom. It is critical that the security
officers enforce the directive that inmates properly wear masks. I did not
physically go into the asymptomatic medical isolation units, but those inmates
should only be coming out alone with masks properly worn until their medical
isolation is lifted.

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FINDING #4
1. During my jail inspection, it was apparent to me that living unit security officers
are not following the directive that ALL inmates should be receiving free bars of
soap not just the indigent inmates.
RECOMMENDATION #4
1. At the daily shift supervisors meeting, jail command staff should issue a directive
to the floor Sergeants, Lieutenants, and Captains requiring them to direct living
unit security staff to distribute free soap to the inmates in every unit twice a week
until further notice. Furthermore, living unit security staff should provide each
new inmate who enters the living unit with an information sheet that provides the
inmate with Covid-19 education materials and a statement that they are entitled to
free soap twice a week and that they will not be written up if they have more than
one bar of soap in their possession. If security staff do not follow this directive,
they should be disciplined.
FINDING #5
1. During my jail inspection, I found that the mops used for cleaning were not
disinfected frequently enough and the mop heads changed frequently enough.
Clean towels for cell cleaning were not available to inmates. In some living units,
it was obvious that none of the housing officers on any of the three watches were
ensuring the living units, dayroom areas, and the bathrooms were being mopped
and scrubbed. Spraying Biovex on the toilets and in the bathrooms is inadequate.
The floors need to be mopped regularly and the toilets and showers scrubbed
regularly. This was not the case in every unit, but it was certainly the case in some.
RECOMMENDATION #5
1. Twice a week, every living unit in the jail should have a deep cleaning overseen
by the security officer and the living units should be inspected by the floor
sergeant. Inmates should have the opportunity to clean their cells every day at a
specified time that does not take away from their dayroom time. If the living unit
is not spic and span, the inmate’s dayroom time should be suspended until such
time as the living unit is spic and span. In addition, the living unit security officer
should be disciplined for not keeping their living unit clean. Taking pride in your
work area is a fundamental principal and best practice for a paramilitary
organization.

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FINDING #6
1. During my inspection, I did see episodic violations of the mandatory mask policy
for staff and inmates. I also witnessed Sergeants and Lieutenants not strictly
enforcing the mandatory mask directive. I also witnessed security staff that had to
be told repeatedly to pull their mask up over their nose. Staff should not have to
be told two or three times to properly. In the intake/booking area, I witnessed an
inmate enter the interior booking area without a mask. He was allowed to walk
around the booking area without a mask for some time. A Memphis Police Officer
also was not wearing his mask correctly.
2. In my expert opinion, some floor Sergeants, and Lieutenants are over familiar
with their subordinates. By that I mean, they act like friends rather than the
supervisor of the rank and file security staff. As a result, the rules are not
rigorously enforced, rank and file security staff are not held accountable and
disciplined for not following the Covid-19 directives. In one instance, 3 rank and
file security staff were in a Sergeant’s office with the Sergeant and they did not
have their masks on and they were not properly social distancing. This should
never happen.
RECOMMENDATION #6
1. Floor Sergeants, Lieutenants, and Captains need to be hypervigilant in enforcing
the mandatory mask directive for staff and inmates. In fact, they need to be
hypervigilant in enforcing all of the Covid-19 policies, procedures, and practices.
2. It is critical that supervisors maintain their professional distance from
subordinates. Overfamiliarity breeds contempt and as a result supervisors become
unwilling to enforce policy and discipline non-compliant subordinates. This will
poison the well and all the great work that management has done to fight the
spread of this virus will go for naught, and many of the vulnerable inmates will
unnecessarily become seriously ill and die.
3. I recommend that Chief Fields and Assistant Chief Hubbard increase their
presence on the decks and spot check compliance with the Covid-19 policies,
procedures, and practice including the cleanliness of the living units, dayrooms,
and bathrooms.
4. I recommend that the jail consider creating a compliance unit whose sole
responsibility is to audit compliance with department policies, procedures, and
practices. This unit can develop an internal audit tool and audit the jail quarterly
for compliance. A quarterly report then should be filed with command staff and a
corrective action plan should be developed to correct any identified deficiencies.
This is important to protect the vulnerable inmates from an unreasonable risk of
harm due to policy violations.
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FINDING #7
1. The Covid-19 educational materials are not at a 6th grade reading level. The
materials are posted on the wall, and there is a Covid-19 education cartoon that is
played at 0800 and 1500 hours every day on the living unit TVs. Many inmates in
the jail are learning disabled, developmentally disabled, and seriously mentally ill
and do not understand the word or concepts on the Covid-19 material.
RECOMMENDATION #7
1. Create a Covid-19 information sheet that is at a 6th grade reading level. This
information sheet should be provided to every inmate who is booked in the county
jail and again when they reach their assigned housing unit after being taken off
medical isolation. It should also be posted on the wall of every living unit, and the
living unit security officer should make sure the inmate understands the
information on the sheet when they orient the inmate to the living unit rules and
regulations. This information sheet should be available in audio and large print for
the visually impaired and blind.
FINDING #8
1. Cleaning supplies for high touch surfaces such as telephones and kiosks are
not readily available for inmates to use after each inmate uses those high
touch items.
RECOMMENDATION #8
1. Place an EPA approved cleaning solution in a spray bottle with a supply of paper
towels in an area in the living unit where inmates can readily access it for
cleaning the phone, kiosk and other surfaces after every use. The jail is a Direct
Supervision Jail, and security staff are in the living units and can supervise its use
or assign a pod worker to that responsibility. Many inmates are indigent and
assigning inmates with a pay number at .20-.50 cents an hour will allow the
inmate pod worker job to be attractive. First Watch and Second watch can each
have their own pod workers to assist the housing unit security officer with the
management of the cleaning supplies.
FINDING #9
1. Some inmate masks I observed were in disrepair and were dirty. Inmates only are
issued a single mask.

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RECOMMENDATION #9
1. Issue the inmate population two cloth masks one of which can be exchanged with
the weekly laundry exchange. During laundry, the masks should be inspected and
replaced if they are in disrepair. Masks should not be sprayed with Biovex. The
manufactures warnings state that Biovex is considered to be a mild irritant and
can cause irritation of the eyes, ears and throat. Vulnerable inmates may have an
adverse reaction to this substance being sprayed on their masks especially those
with COPD or moderate to severe asthma.
FINDING #10
1. Wellpath does not test for Intellectual Disabilities or Learning Disabilities.
Currently a Psychiatrist interviews inmates who are suspected to be intellectually
disabled, but there is no testing for learning disabilities. Identifying the
intellectually disabled and the learning disabled is important for informed consent
as well as effective communication and victimization concerns.
RECOMMENDATION #10
1. Wellpath may want to consider hiring a Clinical Psychologist to test for
intellectual disabilities and learning disabilities. Some experts have found that
there may be as many as 2-4% of the inmate population that are intellectually
disabled with a much smaller percentage being profoundly intellectually disabled
needing high adaptive supports and protection from victimization.
FINDING #11
1. During my inspection and interviews, I came to the conclusion that there is no
concentrated and coordinated effort to assemble and present information to the
courts regarding an inmate’s medical conditions that may make him vulnerable to
serious illness or death while housed in the jail. Moreover, while I find Mischelle
Best, the Court Expeditor, to be hard working and passionate about her job, I am
concerned she is spread too thin and has to do the job of a competent criminal
defense attorney in addition to her other duties. Nor is there any consistent multidisciplinary effort within the jail to secure alternative custody venues for
vulnerable inmates. I found that a significant number of these inmates had very
serious charges, but some have been charged with garden variety felonies and, in
my expert opinion, because of their medical condition are not a current threat to
public safety if they were placed in a structured and supervised environment.
RECOMMENDATION # 11
1. Create a multi-disciplinary task force within the jail to present the medical
conditions of the inmates who along with their non-violent offenses make then
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good candidates for release to alternative custodial settings. Technology has come
a long way and alternatives custodial environments work well in many other
states and jurisdictions.

.

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CONCLUSION
During the course of my jail inspection, I came to believe that the Shelby County Jail
leadership team are consummate professionals who do embrace and promote the “care”
component of the inmates in their custody, care, and control. They repeatedly told me
that they were open to making any changes that would improve their operation and
increase the health and safety of all the inmate population but especially the vulnerable
inmate population. Their ability to decrease the size of the inmate population in the jail is
limited by their authority to limit the intake of new inmates and by their complete lack of
authority to place any inmates in alternative custodial environments. The fact that the
Shelby County Jail is accredited by the ACA and the National Commission on
Correctional Health Care is evidence of their desire to have a well-run jail that delivers
patient centered healthcare. What I found during my inspection were opportunities for
improvement in some critical areas that are plagued by episodic violations of wellintentioned and well thought out policies procedure and practices designed to maximize
the protection of the vulnerable inmate population.
The Shelby County Jail medical provider, Wellpath, is also dedicated to delivering
patient centered, competent medical care to all the inmates but especially to the medically
fragile inmates who are the most vulnerable to serious illness or death from the Covid-19
virus. The effort of Wellpath to deliver consistent care to the inmates with chronic
illnesses and serious medical conditions is hampered by the unwillingness of outside
hospitals and specialty clinics to treat inmates. I find that deeply offensive and dangerous,
but I am hopeful that Dr. Bruce Randolph can assist Wellpath and the Shelby County Jail
in expanding the medical resources available to them in the community to treat those
inmates who are in desperate need of treatment of their chronic diseases and serious
medical conditions. The inmates in the Shelby County Jail are members of the Shelby
County Community and most of them will return to the community in less than 18
months. Ironically those same inmates who are currently being refused treatment by
community providers and hospitals will seek treatment at those very same hospitals
without shackles and will not be refused treatment.
Given the reality of what is occurring with the Shelby County Courts and the inability of
the jail to reduce its population, the jail and its medical provider must adjust their Covid19 response strategy for the protection of all inmates but especially the vulnerable
inmates.
The jail is a high-risk environment for these vulnerable inmates, and I am hopeful that my
recommendations will be adopted in order to reduce their risk of infection and serious
illness or death.
No jail will ever be perfect in performing its duties, but the Shelby County jail must
embrace the necessary changes to its Covid-19 response strategy or risk losing control of

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its jail to a plethora of class action lawsuits, restraining orders, and/or population caps.
The choice is theirs to make.
Thank you for the opportunity to work on this very important project.

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Signature
Respectfully submitted,

June 29, 2020
Mike Brady
Director
Sabot Consulting

Date

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EXHIBIT 1 – INSPECTION ORDER

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