See Boston Globe Article The Geoghan Panel Report: What It Says- and What It Misses
by Lloyd Fillion and Tracy Serdjenian, Criminal Justice Policy Coalition. March, 2004
The Context for the Panel
On August 23, 2003, John Geoghan, a former priest convicted of a single count of child molestation, was murdered in his cell in Souza-Baranowski MCI (SBCC) by another inmate- John Druce (p. 1). Mr. Druce entered Mr. Geoghan's cell, jambed the door shut and strangled Mr. Geoghan. Shortly after this murder, correctional officers were able to force the door open, seize Mr. Druce and allow a medical team to attempt to resuscitate Mr. Geoghan, who was finally pronounced dead at an area hospital.
Given the high profile nature of the deceased, particularly because he represented the many recently publicized cases of child molestation by clergy, on September 4th, Gov. Mitt Romney, through his Secretary of Public Safety Edward A. Flynn, named a panel of three to investigate “…the circumstances, conditions, and related factors surrounding the death of Inmate John Geoghan. This investigation would review all pertinent practices, policies and procedures, as well as all systemic processes and decision-making procedures concerning Inmates Geoghan and Druce.” (p.8).
The Geoghan Panel (Panel) immediately came under public criticism as composed of individuals too close to the systems they were charged to investigate. In late September, the Senate Chair of the Joint Committee on Public Safety Jarrett Barrios announced to the press that his committee was considering appointing a commission to do a thorough investigation. The announcement came after a tour of SBCC, scheduled well before the murder, by committee members. Shortly thereafter, on October 17th, the Governor announced a larger sixteen member Governor's Commission on Correction Reform (GCCR, alternately the Harshbarger Commission after the chair, Scott Harshbarger) to look at the Department of Corrections (DOC) and submit its recommendations within six months. The joint committee held its first hearing on corrections issues on October 28.
The MA State police also conducted a homicide investigation immediately following the murder, in preparation for indicting Mr. Druce on murder charges. That investigation's reports were made available to the Panel.
Perhaps because the GCCR was created before the Panel completed its work, that Panel's Report (Report) was relegated to a footnote in the public's attention. In January, the executive branch of the government announced that the Report had been submitted, but was likely not to be released to the public. This caused another round of objections. On February 3rd, the Report, undated, was made available to the general public in a redacted version. The names of a number of correctional officers (COs) were blacked out, as were substantial sections of conversation by both inmates.
Contents of the Report The Report includes an executive summary, for the most part in a series of key questions and answers. Following an introduction/overview are six sections which cover specific areas:
A: Goals and Objectives – why the investigation was undertaken, its purpose and importance (italics in original) ; B: Approach and Methodology - biographies of the investigators and how the investigation was approached; C: Background –detailing the who, what, when and where of the incident; brief histories of the two inmates; a description of the two main correctional institutions and overview of security levels; description of two MA Supreme Judicial Court (SJC) decisions which control key relevant operations of the DOC; a review of DOC investigation operations; and a history of the physical abuse of Geoghan by COs; D: Findings and Conclusions – divided into four categories: Investigations, Disciplinary Reports, Classification, and Staffing and Operations; E: Recommendations; F: Photographs.
The Report concludes with lists of documents reviewed, and a time line for the two inmates from their initial commitment to the day of the murder (p. 19).
The Panel's Recommendations: A Condensation of Section E
Discipline Reports: Discipline Reports (DRs) made by COs concerning inmate (mis)behavior need to be based on training and guidelines. There should be systematic review of all Reports by supervisory personal to ensure that the Reports adhere to DOC requirements. All DRs should be placed in a central repository in order to allow management to review them, with an eye to identifying patterns which may require attention, either in the actions of the issuing COs or in inmate behavior. The issuing COs should be given feedback from all reviews, to allow them to learn from such reviews. Consideration should be given to centralized oversight of the disciplinary function.
Special Housing Unit: Assignment of Staff: Staffing for Special Housing Units (SHUs) should be uniform throughout the entire system. COs chosen to work in these units should be specially selected and specially trained.
Staff Briefing/New inmates on Housing Unit: Staff in all housing units should be given histories of all inmates transferred to their housing units, in order to ascertain special needs, or the need for extra vigilance.
Investigations: All internal investigations by DOC staff should be better supervised, and should follow appropriately defined practices. Inmate complaints should be reviewed by independent appeals personnel for possible investigation, and all investigations and appeals should be centrally housed.
Cell Doors at SBCC SHU: Doors to the cells at SBCC need to be modified to prevent inmate jambing, and emergency access by DOC personnel should be enhanced.
Classification: Classification of inmates needs uniform throughout the system. Appeals by inmates must be objectively reviewed by officers different than those who made the initial classification. Mental health input is essential.
MCI Concord SHU: The SHU at Concord MCI does not provide the required protective custody from the general inmate population. The unit needs either to be moved to another prison, or further restrictions on SHU inmate movement must be instituted.
Inmates Legally Changing Names: Inmates who legally change names while in DOC custody should have their files flagged so that change is quickly noted. The DOC should have legislation introduced to prohibit name changes by inmates while in custody, except for religious reasons.
SBCC SHU: Limitations on Inmate Interaction: At the SBCC SHU, inmate movement should be limited so that no more than 5 inmates are allowed out of their cells at meals at any one time.
SHUs: Department Oversight: Assignment to SHUs should be under the management of a central office, as an aid to detecting potential conflict between individual inmates.
Correction Officer Nametags: All COs should be required to follow department regulations regarding wearing nametags.
Blaney Case: The 1978 Blaney v. Commissioner of Corrections decision by the SJC should be judicially reviewed. This decision affirms the right of inmates in protective custody to the same standard of treatment and opportunities as the general population; however, this principle should be carefully enforced in ways that do not compromise the paramount issue of inmates' safety .
Placement of Protective Custody Inmates: Classification level 4 inmates should not be housed with level 6 inmates.
Monitoring Facility Operations: The DOC management should re-assess the manner in which it determines that individual facilities are in compliance with policy, procedures, and post orders.
CJPC Reservations and Additional Recommendations
The Geoghan Panel Report does focus on a number of procedures and policies which contribute to an environment conducive to the murder at the center of the investigation. However, the Report is not exhaustive; in particular, it omits several points which would strengthen the DOC's ability to respond to needs identified by the conclusions.
This may be because the Report does not say why the investigation was undertaken. Early in the text, the Report states that Secretary of Public Safety Edward Flynn ordered the Panel to do “…an administrative investigation into the facts and circumstances surrounding the events which led up to Inmate Geoghan's death.” (p. 2). Later, the Report asserts that the “why” is consonant with the purpose and importance of the investigation (p. 10). However, nowhere does the Report specifically state the reason Secretary Flynn called for this investigation; thus its goals, purpose and importance remain unclear. Panel members seem to have been driven by the need to make an investigation for the Secretary rather than the need to address a set of goals or issues, or underlying causes. A clear statement of “Why” the report was requested would have assisted directing the investigation, the Report, and its use.
All of the omissions arise out of, and focus on, the “Findings and Conclusions” section (pp. 61-99). They are organized here according to the divisions used in the original Report. Each contains one or more recommendations which the Panel's own investigation suggest. Such recommendations are in bold type.
Investigations: Documentation of Injuries
Reservation 1 Inmate Druce had an extensive history of disciplinary problems dating from his first confinement in 1989, and he was known to have drawn up a list of 50 other inmates throughout the DOC system who were personal enemies. Immediately prior to his confinement in the Department Disciplinary Unit (DDU), hours after an interview with a shift commander, injuries were noticed on Mr. Druce and he was taken to the Health Service Unit. Over the course of the next several days, Mr. Druce gave conflicting accounts of his injuries. He initially charged a CO with kicking and punching him, causing the facial injuries. But later, in a different interview with another investigating officer, Mr. Druce asserted he had sustained the injuries in a fall due to a seizure. The second investigating officer concluded that the cause of the multiple injuries on his face and body could not be determined. The Report discusses this both in the biography of Mr. Druce on page 35, and again in the ‘Findings and Conclusions' section on pages 65-68. Of note is that the two sections of the Report itself are in conflict with each other regarding which explanation Mr. Druce offered first about the cause of his injuries.
The Panel finds the investigation of this incident at Cedar Junction MCI flawed because personnel were inexperienced and poorly trained, and supervisors failed to require higher investigatory standards. However, the Report does not comment on the documentation of the injuries themselves. The Panel had access to medical records; yet there was no mention of photographs of the injuries—though it should be noted that several lines of text were redacted from the publicly available version of the Report. In fact, the Report contains no comment on the thoroughness of the medical personnel's records or observations. If there were no photographs taken by the medical staff, (and others familiar with the health service units procedures report that photos are not common practice) that absence should have been noted and a recommendation made that photographs be a standard part of recording all injuries.
Reservation 2 Mr. Geoghan received an extraordinary number of DRs while at Concord. In fact, he received 20% of the 77 DRs written regarding the 25 inmates of the J-4 SHU during a 16 month period on that block (Mr. Geoghan was there for about 14 months of that time). Of particular note, Mr. Geoghan accounts for 40% of DRs written by CO Bisazza (pp. 75,77) during that period. This was more than any other inmate within that block.
According to MCI Post Orders, Disciplinary Reports should be reviewed by the shift commander, and the area Lieutenant should be notified, to ensure the validity of the DR. In their review of the abuse of DRs, the Report further cites the Post Orders as emphasizing that “Informal Resolutions between the officer and the inmate are the preferred method of dealing with minor infractions. When informal resolutions are impractical, or in cases of serious infractions, it will be necessary to write a disciplinary report.” (p. 69, italics added; original in bold type).
N.B. ARE IRs DEFINED IN DOC REGS???The Geoghan Report does not define or critique “Informal Resolutions,” a term which suggests a sizeable level of discretion given to COs. This appears to allow substantive subjectivity to enter what should be a very controlled administration of punishment. Infractions subject to Informal Resolutions should be listed, with appropriate discipline, and this list made available to COs and inmates. Exceptions might be written into the Post Orders for very simple violations that would incur a very minimal response. Such exceptions should be defined so that individual infractions can not be broken up into a series of continuing actions providing for a continuing punishment meted out day after day, as a means of circumventing the intent of controlling the use of Informal Resolutions.
Reservation 3 The Report recommends a central repository for DRs and supervisory personnel review each DR for compliance with DOC regulations and for quality. While the latter step could in principle act as a feedback loop to identify abuses of DR policy, it stops short of recommending frequent reviews for questionable patterns. This is an important oversight, as quarterly and even monthly reviews might not catch problematic patterns in time. The DOC should develop a schedule of reviewing DRs for questionable patterns in a timely fashion.
Additionally, modifications need to be made concerning the use and status of DR's once issued. These include :
a. DRs not written in compliance with policy should not be considered by the Classification Board; the Classification Board should be informed of the results of DR reviews, so that they will be aware of any DRs that were deemed to be excessive; b. no inmate should be punished as a result of DRs written in a manner that fails to comply with DOC policy; c. there should always be an appeal process available to the inmate to challenge the appropriateness and/or level of punishment.
Reservation 4 Mr. Druce was confined to the Department Disciplinary Unit (DDU) at Cedar Junction MCI for four years immediately prior to his transfer to SBCC SHU on May 29, 2003, three months before the murder (pp. 35-37). The Report reviews the possible implications had Mr. Druce been allowed to “… decompress from four years in the DDU…” before being sent to the SBCC SHU (p. 85). The Panel concludes that, given the need to isolate Druce from the general inmate population at Cedar Junction MCI, such a period would not have influenced the outcome in this case. However, at no point does the Panel investigate the impact of 4 years of solitary confinement, whether that length might in and of itself have been a contributing cause, or even cite that as an issue needing further investigation. The effects of solitary confinement, and the use of solitary confinement within the prison system, need to be thoroughly reviewed, with input from mental health professionals aware of research on the likely consequences of such confinement.
Reservation 5 The process and criteria of selecting COs to sit on Classification Boards varies among the several prisons in the Commonwealth, as noted in the Report (p. 82). In some cases, COs are chosen who work in the housing units from which the inmates being (re)classified come; in other instances there is a deliberate effort to have COs review the files of inmates about whom they have no direct knowledge. The Panel opines that the former policy is preferable, since it is clearly more meaningful to have inmates classified by COs who know them. However, the difficulty lies in the loss of objectivity that such proximity encourages, which can result in either over- or under- classification. If DRs are properly used, an accurate picture of the inmate's behavioral record can be made available for the Classification Board. With the proper classification training which the Panel rightly calls for (see above), a preference for board members with no prior knowledge of inmates has a distinct advantage for both the inmate and the CO. The Panel affirms the need for objectivity regarding appeals of these classification decisions. Objective review of subjective evaluations can only determine if there is consistency in the subjectivity, not whether those subjective evaluations are appropriate. Given that, the Panel's preference for a subjective evaluation at the initial stage is not supported, and should be reconsidered.
Reservation 6 The Concord Classification Board initially recommended that Mr. Geoghan stay in Concord; however, the Deputy Superintendent at Concord overruled this determination, reclassified him to a level 6 inmate and transferred him from Concord MCI to SBCC (pp. 25-27). Mr. Geoghan appealed this transfer three times in writing, noting in one appeal that he was a “model prisoner and [had] problems with only C.O. Bisazza and associates. (p. 79).” The third appeal was two weeks after he had arrived at SBCC; 10 weeks later he received his last rejection. Ten days later, during a classification hearing at SBCC, Mr. Geoghan evinced a comfort and sense of security at SBCC saying “it's like heaven here (SBCC) and Concord was like hell.”(p.27).
Coupled with the interpretation of Mr. Druce's several comments about the injuries he received (see Section C above) and also the weighing of conflicting comments by Mr. Geoghan regarding feces found in his cell (p. 63) there appears a tendency by the Panel to accept inmate comments if they fit in with previous expectations of staff. However, there is no acknowledgment that these contradictory statements by inmates may amount to a survival technique by inmates concerned about their personal wellbeing in a potentially dangerous situation.
Lack of consistency in an inmate or CO's statements should be reason for further investigation, rather than for concluding that the truth cannot be known. At a more fundamental level, the ‘survival technique' analysis merits attention and should be explored in depth, as it raises another issue of serious concern and with widespread implications—that these patterns point to a level of fear and/or hostility within the DOC's institutions which does not encourage truthfulness and respect between inmates and COs and/or administration.
Staffing and Operations
Reservation 7 The Panel notes that the two officers on duty in the SBCC SHU the day of incident had “swapped” for this detail (p. 89). Swapping details is an administration accepted way for COs to combine their work into two shifts on two consecutive days and one shift on the third consecutive day, thereby obtaining four day weekends. The Panel raises questions regarding the potential detriment to the DOC of allowing swapping if it results in personnel taking posts for which they are not trained. The Panel notes that these two officers had worked the SHU regularly, allowing the Panel to conclude that swapping was not a problem in the case under discussion. The Report is silent regarding double shifts of any other COs involved over the several year period.
Unfortunately, there is no discussion of the detriment caused by allowing for double shifts, which can place both COs and inmates at risk due to COs' inability to concentrate and react quickly to unforeseen conditions. At the same time, fatigue causes individuals to be less tolerant of abnormal, non-threatening behavior which otherwise would be overlooked. While the practice of swapping is authorized by a memorandum between the DOC and the COs' union, that should not place a questionable practice outside the purview of the Panel. Two Panel members had likely belonged to public safety employees' unions, if so, at the least a disclaimer regarding this issue would be appropriate. The practice of double shifts should be re-examined in light of safety concerns.
Reservation 8 At several places in the Report, the Panel suggest that one clause of the Blaney v. Commissioner of Corrections, 1978 does not work with the current demands of SHUs today (p. 88). The clause in question requires the DOC to provide five hours of “meaningful [educational, work/vocational or recreational] activities” to inmates confined in protective custody units (p. 44). In fact, this is the basis of the Panel's recommendation that Blaney be judicially reviewed, one presumes in order. Nowhere does the Report detail any support for the implied claim that protective custody units and/or prisoners of 26 years ago are substantively different from their counterparts today. The Panel fails to acknowledge that the SJC's decision was predicated on the importance of maintaining the mental health of inmates, and no justification is provided for dismissing this as a reasonable and valid concern of the correctional system. Blaney v. Commissioner of Corrections should be upheld, and current practice should be modified to conform to that decision, in the absence of any other serious, system-wide reconsideration of the need to provide meaningful educational and/or vocational activities to inmates. In particular, the DOC should look into ways to better meet the requirements of Blaney v. Commissioner of Corrections without compromising the safety of inmates and COs.
Reservation 9 Findings/Conclusions nos. 5 through 7 examine three distinct events of inmate/CO interaction deemed to require attention (p. 92-93). Two of these involve situations not clearly covered by existing regulations; a third involved violation of a regulation. The response of the Panel in each instance is to recommend further regulation of guards and inmates, resulting in increased restraints on movement for both.
It is important here to consider the nature of the alleged problems. The one incident involving a violation was a case where inmate returned another inmate's lunch tray for him. The other two situations involved a lack of specificity in determining, respectively, which CO is responsible for which duty in the SHU, and how many inmates may pick up or return food trays at one time in the SHU.
The recommended solution to this issue impacts the entirety of the DOC environment. It is widely known that inmates already face substantial challenges when adjusting to the self-regulated life they must lead after they are released from the highly regimented life of prison. Preparation for life should begin from the day that inmates begin their incarceration. Unfortunately, the prison system now lacks the necessary transitional programs to allow for this adjustment. Further increasing the restrictiveness of the prison environment can only worsen this situation. Learning individual responsibility within and for a diverse community is a key part of rehabilitation and transition. Additional regulations, or mandating stricter enforcement of existing regulations, should be considered only with serious justification; reducing expectations can only function adversely, and ultimately work against the correctional system's goals and the society's need for inmates to become fully functional citizens on their release.
None of the recommendations in the foregoing section require a significant increase in the DOC budget, with the possible exception of the recommendation regarding double shifts. However, cost-benefit analyses have a limited role to play if the sine qua none of Corrections is safety and rehabilitation.
If the “why” of the Report is to learn as much as possible from mistakes associated with the murder of Mr. Geoghan, with an intention of reconsidering policies and staff habits, there should be no area not subject to such re-evaluation.