A report commissioned by Allegheny County Jail found “no significant trends or common factors that would show a particular weakness or gap in operations” that led to 27 inmate deaths at the jail over five years.

A redacted copy of the 50-page report from the nonprofit National Commission on Correctional Health Care was released Thursday. The county requested the review after four people died at the jail during the first seven months of last year.

Of 27 deaths at the jail between 2017 and 2022, the report said 11 were attributed to natural causes, seven to suicide, six to accidental causes and three were listed as undetermined or pending.

None of the deaths resulted from the use of force by jail personnel or violence from others incarcerated there, the report found.

The report said there have been no suicides at the jail since April 2020. In 2019, the NCCHC prepared a report for the jail with recommendations on suicide prevention. The report released Thursday said almost all of the recommendations in that report have been implemented.

“Allegheny County and the administration of the ACJ have implemented significant changes to the physical structure, staffing and training within the facility to enhance efforts to protect the lives of patients housed within their facility,” the report said.

A team of four people from the organization visited the jail from Nov. 1 to Nov. 3. Warden Orlando Harper provided a tour of the jail and the team interviewed Harper, intake supervisors, nurses, administrators and mental health staff.

The team also analyzed the circumstances around the 27 deaths and how they were reviewed afterward. As part of that work, the report said policy violations occurred.

For example, in some of the suicides, officers had failed to complete their rounds to check on the incarcerated people who killed themselves. In another case, the report said officers found a person hanging in a cell and instead of immediately initiating CPR, they called medical staff and waited for them to arrive.

“In incidents where staff were found to have violated policy, ACJ administration took timely disciplinary action against involved staff who violated policy and held the employees accountable,” the report said.

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The report also made recommendations.

Among them, it said people identified with poorly controlled chronic conditions should be treated within seven days of incarceration, and medical providers should adopt evidence-based clinical protocols in their treatment.

Those entering the jail with substance abuse disorder should be started on detoxification immediately and managed, the report said. Those entering with a history of suicide attempts or psychiatric hospitalizations should be seen by a qualified mental health provider within 14 days, it added.

The report also said that officers checking on people incarcerated at the jail should be checking for signs of life and not just walking by each cell.

The report also recommended that a nurse at the jail should conduct a thorough assessment of those entering the facility and be trained to recognize abnormal vital signs, evidence of detoxing and a history of suicide attempts.

The NCCHC said documentation received by its team reviewing in-custody deaths was inconsistent and made it difficult to get a clear picture of each incident, the person’s behavior and activities. The organization said the jail should create a checklist to ensure thorough reporting.

The report also dealt with the relationship between the jail administration and jail staff and said the relationship between the administration and Jail Oversight Board is strained.

Regarding the board, the report said the problem “seems to be driven more by one member of that board than the process itself. Having a relationship with that board is critical as it is a Pennsylvania law that establishes their authority, and they do have authority and the responsibility for oversight of the facility. This relationship needs to be addressed immediately.”

Board member Bethany Hallam, an Allegheny County councilwoman, is presumably that “one member,” though she isn’t named in the report. Hallam has been outspoken about issues at the jail during her time on the board and has been particularly focused on health care and mental health care, along with violations of a ban on solitary confinement, inadequate food and incarcerated individuals being forced to work without pay.

She often asks dozens of questions at the monthly meetings, while others board members ask none.

On Friday, Hallam was critical of the county for failing to provide any previous drafts of the report to the board and for waiting to release it during the March meeting.

“It’s hard to view this as anything other than yet another superficial press stunt by the county administration to distract from the abysmal human rights record of the jail,” Hallam said. “It’s ridiculous, and if there weren’t people suffering and dying every day as a result of their incompetence and cruelty, I would maybe even laugh about the absurdity of it all.”

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