# Braggs v. Dunn

> District Court, M.D. Alabama · May 4, 2019 · 383 F. Supp. 3d 1218

URL: https://www.frixlaw.com/law-library/cases/7254134

## Case

- **Full name:** Edward BRAGGS v. Jefferson S. DUNN, in his official capacity as Commissioner of the Alabama Department of Corrections
- **Court:** District Court, M.D. Alabama
- **Decided:** May 4, 2019
- **Citations:** 383 F. Supp. 3d 1218
- **Precedential status:** Published
- **Opinion:** Opinion of the court by Thompson
- **Judges:** Thompson
- **Cited by:** 7 later opinions in the Frix Law Library

## Citator (automated)

- No negative treatment found by the automated citator. That is not the same as a confirmation that the case is good law; read the citing cases.
- Full citator and citing cases: https://www.frixlaw.com/law-library/cases/7254134

## How later opinions describe it (automated extraction)

- finding the defendants’ agreement to a remedial provision is strong evidence of PLRA compliance

## Opinion text

Myron H. Thompson, UNITED STATES DISTRICT JUDGE
In this long-standing lawsuit, the court previously found that the Alabama Department of Corrections (ADOC) has failed to provide adequate mental-health care to inmates in its custody in violation of the Eighth Amendment to the United States Constitution. See Braggs v. Dunn , 257 F. Supp. 3d 1171 (M.D. Ala. 2017) (Thompson, J.), Braggs v. Dunn , No. 2:14CV601-MHT, 2019 WL 539050 , 367 F. Supp. 3d 1340 (M.D. Ala. Feb. 11, 2019) (Thompson, J.). More recently, in the wake of 15 inmate suicides in a 15-month period, the plaintiffs asked for immediate suicide-prevention relief. For reasons that follow, the court concludes that these suicides, as well as *1227 other evidence in the record, show that ADOC continues to fail to provide adequate suicide-prevention measures and, thus, subjects inmates to a substantial risk of serious harm, including self-harm, continued pain and suffering, and suicide. The risk of suicide is so severe and imminent that the court must redress it immediately. Therefore, the court will grant the plaintiffs' motion for immediate relief by making permanent most provisions of an interim suicide-prevention agreement that the parties reached early in this litigation; by adopting, in large measure, the recommendations proposed by experts for both parties; and by requiring court monitoring that is limited to the immediate relief ordered here. By agreement of the parties, the issue of non-immediate suicide-prevention relief will be resolved by the court later.
I. PROCEDURAL BACKGROUND
The plaintiffs in this class-action lawsuit include a group of seriously mentally ill state prisoners and the Alabama Disabilities Advocacy Program (ADAP), which represents mentally ill prisoners in Alabama. During the liability trial, and in response to the suicide of class member Jamie Wallace just days after he testified, the parties agreed to a series of interim suicide-prevention measures. See Interim Agreement (doc. no. 1106-1). The court reduced this 'interim agreement' to an order. See Interim Relief Order (doc. nos. 1106, 1106-1).
In June 2017, the court issued a liability opinion in which it found that ADOC's mental-health care for prisoners in its custody was, "[s]imply put, ... horrendously inadequate" and violated the Eighth Amendment. Braggs , 257 F. Supp. 3d at 1267 . The court more specifically found that "ADOC's inadequate crisis care and long-term suicide-prevention measures have created a substantial risk of serious harm, including self-harm, suicide, and continued pain and suffering." Id. at 1220 . The "serious" suicide-prevention deficiencies identified by the court included ADOC's failure to provide crisis care to those who need it; placement of prisoners in crisis in dangerous and harmful settings, including unsafe crisis cells; inadequate treatment for prisoners in crisis care; inadequate monitoring of suicidal prisoners; inappropriate release of prisoners from suicide watch; and inadequate follow-up care for prisoners released from suicide watch. See id. at 1218-31 . Moreover, the court found that these risks are particularly heightened for prisoners with serious mental illnesses. "Serious mental illness" (SMI) is a term of art used in the field of psychiatry which refers to "a subset of particularly disabling conditions ... defined by the diagnosis, duration, and severity of the symptoms." Id. at 1246 . Certain conditions are always considered SMIs, such as schizophrenia, bipolar disorder, and major depressive disorder. See id. at 1186 n.6.
Over a period of months, the court adopted several 'remedial orders' regarding mental-health care that touched on suicide prevention. 1 To fashion a comprehensive suicide-prevention remedy, the parties agreed to, and the court accepted, a process whereby Drs. Mary Perrien and Kathryn Burns, the defendants' and plaintiffs' correctional mental-health experts, respectively, would "assess ADOC facilities and operations related to suicide prevention *1228 and provide a report with recommendations to resolve the constitutional violation determined by the Court in the Liability Opinion and Order." Joint Notice (doc. no. 2014) at 1; Order (doc. no. 2020) (adopting the parties' plan for assessing suicide-prevention measures).
On January 18, 2019, before the parties' experts completed their report, and in response to a series of suicides, the plaintiffs filed an emergency motion regarding the placement of high-risk prisoners in segregation. See Motion for Preliminary Injunction (doc. no. 2276) at 1. The court construed it as seeking permanent, albeit immediate, relief. See Order (doc. no. 2345).
On March 8, the experts filed (1) a report with recommendations for relief, (2) a report identifying a subsection of those recommendations to be implemented immediately in light of the recent suicide crisis plaguing ADOC, and (3) case summaries of many of the recent suicides. See Joint Expert Report and Recommendations, Immediate Relief Recommendations, Joint Expert Case Summaries (doc. nos. 2416-1, 2416-4, 2416-2). Their reports were the product of an extensive and thorough study, in which they reviewed thousands of documents from ADOC, toured multiple facilities, and interviewed both prisoners and staff.
In March and April, the court held a trial to determine whether immediate and non-immediate suicide-prevention relief is needed and, if so, what it should be. The parties and the court decided during the hearing that the portion of the hearing on non-immediate suicide-prevention relief would be continued to a future date. This opinion addresses only immediate relief in response to the ongoing substantial and pervasive inadequacies in ADOC's suicide-prevention efforts, exemplified by the 15 suicides that have occurred since December 2017.
As immediate relief, the plaintiffs first request that the court enter an order making permanent most of the provisions of the interim agreement. The agreement addressed licensing of mental-health professionals; suicide-watch procedures, including inmates' placement on and discharge from suicide watch, follow-up appointments upon discharge, and documentation requirements; and suicide risk assessments, including a monthly evaluation of assessments.
The plaintiffs also request that the court adopt as an order the experts' second report. This report identifies a subsection of their recommendations that should be implemented on an immediate and permanent basis. These 'immediate relief recommendations' address suicide-watch follow-ups, referrals to higher levels of care, preventing discharge from suicide watch to segregation, training for staff, security checks in segregation, confidentiality, and immediate life-saving intervention. In addition, the plaintiffs seek interim monitoring of the immediate relief.
Finally, the plaintiffs also argue that the defendants are placing mentally ill prisoners in units that, while not labelled as segregation or restrictive housing, impose equally severe restrictions on out-of-cell time, and the same accompanying risk of serious harm, particularly suicide. Therefore, they contend, the court's relief should extend to these "segregation like" settings.
The court heard substantial evidence suggesting that prisoners in certain units receive very little out-of-cell time. However, the court needs more time to consider the evidence, and may decide to solicit additional input from the parties before deciding this critical issue. Therefore, the court's findings remain open as to this discrete issue, and the court will take it up after this opinion is issued.
*1229 II. RECENT SUICIDES 2
Fifteen men in ADOC custody have committed suicide since December 30, 2017, an average of almost one suicide per month. An examination of their cases illustrates severe and systemic inadequacies in ADOC's suicide-prevention efforts. Many of the inadequacies, detailed in the 15 cases below, are instances of ADOC's pervasive and substantial noncompliance with the interim agreement and other remedial measures that they agreed to implement; that is, they are examples of what ADOC recognized are "systemic failures to comply with court orders." Pls. Ex. 2710 at ADOC0475738. 3 Other inadequacies, while not necessarily constituting noncompliance with specific remedial orders to date, show ADOC's failure to live up to its obligations under the Eighth Amendment. In sum, both types of deficiencies summarized in the 15 cases below demonstrate that immediate relief is necessary to address the substantial risk of serious harm to which prisoners remain exposed.
Rashaud Morrissette
On March 8, 2019, Rashaud Morrissette hanged himself with a belt in the shower of a segregation unit at Fountain prison. See Crook Apr. 2, 2019, Trial Tr. (doc. no. 2488) at 184; Pls. Ex. 2661 at ADOC0470542. ADOC's suicide-prevention failures in his case include that before entering segregation, he did not receive a critical preplacement screening for issues such as whether he was at risk of suicide or had a serious mental illness (SMI). See Crook Apr. 2, 2019, Trial Tr. (doc. no. 2488) at 185; Burns Apr. 9, 2019, Rough Draft (R.D.) Trial Tr. at 191; see generally Pls. Ex. 2692.
Matthew Holmes
Matthew Holmes killed himself on February 14, 2019, roughly 12 hours after being transferred from mental-health observation (MHO) to segregation at Limestone prison. See Burns and Perrien Apr. 9, 2019, R.D. Trial Tr. at 169, 186. (MHO is a short-term placement that does not have the same level of protections as suicide watch.) ADOC's suicide-prevention failures in his case include (1) not placing him in suicide watch despite his being suicidal, and (2) placing him in segregation despite his having a SMI, and without adequately assessing his suicide risk or referring him for the emergency mental-health care he needed. Specifically:
• On February 11, 2019, Holmes was improperly placed in MHO, rather than *1230 suicide watch. See Defs. Ex. 3613 at SPA_13585. A "Psychiatrist/CRNP Progress Note" on February 12 indicates that he had recently become suicidal after being placed in segregation, and that he had twice attempted suicide in 2010. Id. at SPA_13582. As acknowledged by Deborah Crook, ADOC's Director of Mental Health Services, Holmes met the National Commission on Correctional Health Care (NCCHC)'s definition of nonacutely suicidal, and therefore, under the interim agreement, should have been placed on at least nonacute suicide watch (rather than MHO), at which point a suicide risk assessment would have been required. See Crook Apr. 2, 2019, Trial Tr. (doc. no. 2488) at 55. 4
• Because he was not placed on suicide watch, he did not receive a suicide risk assessment. See id. at 55-56. Furthermore, the parties' experts, Drs. Burns and Perrien, flagged that while in MHO, Holmes's contacts with mental-health staff were conducted inside his cell, "rather than in a confidential area out of cell." Joint Expert Case Summaries (doc. no. 2416-2) at 4; see also Defs. Ex. 3613 at SPA_13581-84.
• On February 14, he was ordered released from MHO to segregation per the order of a nurse practitioner who "wrote no note in the chart explaining the rationale for this decision or the level of risk assessed." Joint Expert Case Summaries (doc. no. 2416-2) at 4. Holmes's February 13 treatment plan review had stated that he was "not making progress toward treatment plan goals," Defs. Ex. 3613 at SPA_13577; however, suddenly, the next day, the treatment plan review concluded that he had "completed treatment goal," id. at SPA_13576; see also Joint Expert Case Summaries (doc. no. 2416-2) at 4.
• The segregation pre-placement screening completed on February 14 at 11:45 a.m. noted that Holmes had a SMI, and that there were "yes" responses to the following three questions: (1) Are you feeling sad, hopeless, or depressed? (2) Have you ever intentionally hurt yourself or attempted suicide? (3) Have you had any serious problems with a significant other, family member or friend recently? See Defs. Ex. 3613 at SPA_13571. As noted by the parties' experts, despite these responses, Holmes "was not diverted from segregation placement and an 'urgent' rather than 'emergent' referral to mental health was made." Joint Expert Case Summaries (doc. no. 2416-2) at 4.
• Later that night, he was discovered hanging from an overhead light fixture in his segregation cell. See id.
• Drs. Burns and Perrien concluded that his case "illustrates the problems with use of MHO rather than approved suicide watch levels, poor documentation of rationale for release from watch, failure to generate an emergency referral to mental health in response to a positive pre-placement screen and releasing SMI inmates from watch directly into segregation." Id.
Daniel Gentry
Daniel Gentry hanged himself at the Donaldson prison Residential Treatment *1231 Unit (RTU) on February 6, 2019. ADOC's suicide-prevention failings include not placing him on suicide watch despite his making clear that he wanted to die, not conducting a suicide risk assessment when indicated, and inadequate review of his suicide. Specifically:
• A few weeks before his death, on January 24, 2019, a mental-health progress note reported that Gentry had asked a correctional officer to kill him. See Pls. Ex. 2314 at SPA_13258. In response, he was placed in MHO that day. See id. As plaintiffs' expert Dr. Burns testified, the MHO placement was inappropriate, because "with someone who's actively voicing the wish that someone kill him, you would expect to start a suicide watch, either acute or nonacute, but not just mental health observation status." Burns Apr. 9. 2019, R.D. Trial Tr. at 94.
• Five days into his MHO placement, Gentry continued to report "auditory hallucinations and a desire for someone to kill him." Pls. Ex. 2314 at SPA_13275. His records indicate that he did not receive a suicide risk assessment in relation to his MHO placement. See generally Pls. Ex. 2314.
• On January 31, 2019, Gentry was released from MHO to the RTU at Donaldson. See id. at SPA_13235; Joint Expert Case Summaries (doc. no. 2416-2) at 3. A week later, on February 6, he was discovered hanging from a light fixture inside his cell during a security check. See Joint Expert Case Summaries (doc. no. 2416-2) at 3. The correctional officers waited several minutes for medical staff, who upon arriving, told them to remove the sheet from his neck and initiated CPR. See id. Dr. Burns testified that this intervention was inadequate, as the officers should not have waited for medical staff to arrive before removing the noose and beginning CPR. See Burns Apr. 9, 2019, R.D. Trial Tr. at 204. Indeed, both Drs. Burns and Perrien noted with respect to Gentry's suicide that correctional officers "need additional training and drills regarding first aid and responding to hanging attempts." Joint Expert Case Summaries (doc. no. 2416-2) at 3. This observation coincides with the experts' more general recommendation that ADOC policy and practice be revised to ensure that as soon as two security staff are present, "CPR should be immediately initiated while whatever method of suicide is eliminated." Joint Expert Report and Recommendations (doc. no. 2416-1) at 29.
• In carrying out their suicide-prevention assessment, Drs. Burns and Perrien did not receive any medical or security reviews of the suicide, see Joint Expert Case Summaries (doc. no. 2416-2) at 3, even though, in their expert opinion, ADOC must conduct such reviews in cases of suicides, see Joint Expert Report and Recommendations (doc. no. 2416-1) at 34. Here, and in the other cases detailed in this section in which Drs. Burns and Perrien did not receive medical or security reviews, the court infers from ADOC's failure to provide the reviews that either the reviews were never conducted, or that--like the limited sample of documents reviewing suicides that they did receive--they were generally inadequate. 5
*1232 Paul Ford
Paul Ford killed himself in segregation at Kilby prison on January 16, 2019, following two prior suicide attempts in segregation in 2018, and less than a month after being released from suicide watch. See Joint Expert Case Summaries (doc. no. 2416-2) at 3. ADOC's suicide-prevention failures in his case include inadequate (1) follow-up mental-health appointments after release from suicide watch, (2) suicide risk assessments, and (3) mental-health assessments while in segregation. Specifically:
• In April 2018, while in segregation, Ford set fire to his cell and attempted to hang himself. See id. ; Pls. Ex. 2309 at SPA_9757. On July 30, he again attempted to hang himself while in segregation and was placed on suicide watch. See Pls. Ex. 2309 at SPA_9741.
• Following his release from suicide watch on August 2, he was placed in segregation, but records indicate that, following discharge from suicide watch, he did not receive the required three-, seven-, and 30-day follow-up appointments. See id. at SPA_9730; see generally Pls. Ex. 2309.
• Ford's initial mental-health assessment in segregation failed to note his history of suicide attempts and left the "assessment" section blank. See id. at SPA_9728-29.
• On December 12, he cut his wrist while in segregation, for which he was charged with a disciplinary violation. See id. at SPA_9670.
• Ford was placed on suicide watch on December 12. See id. at SPA_9702. A suicide risk assessment on December 20 stated that he had no recent "suicidal/self-injurious" behavior or ideation, even though he had cut his wrist just eight days earlier. Id. at SPA_9674. He was released from suicide watch around December 21 and placed back in segregation at Kilby. See Pls. Ex. 2352 at ADOC0462881; Joint Expert Case Summaries (doc. no. 2416-2) at 3. Records indicate that, in contravention of the interim agreement, staff did not complete the follow-up appointments after his release from suicide watch. See generally Pls. Ex. 2309; Crook Apr. 2, 2019, Trial Tr. (doc. no. 2488) at 108; Burns and Perrien Apr. 9, 2019, R.D. Trial Tr. at 123-24.
• On January 16, 2019, Ford was found hanging from his segregation cell door. See Pls. Ex. at SPA_9656. Drs. Burns and Perrien did not receive medical or security reviews of his suicide. See Joint Expert Case Summaries (doc. no. 2416-2) at 3. While ADOC conducted a 'quality improvement' (QI) assessment of the case, both Drs. Burns and Perrien testified that it did not constitute an adequate review of the suicide. See Burns and Perrien Apr. 10, 2019, R.D. Trial Tr. at 114-15.
Roderick Abrams
Roderick Abrams committed suicide on January 2, 2019, the same day he was placed in segregation. Rampant suicide-prevention failures plagued his case, including failing to place him on suicide watch when he expressed suicidality, repeatedly failing to screen him for mental-health issues prior to placing him in segregation, *1233 failing to complete mental-health appointments due to staffing and space shortages, and failing to immediately initiate life-saving measures when he was found hanging in his cell. Specifically:
• Records indicate that Abrams was initially held in segregation between August 23 and December 4, 2018, see Pls. Ex. 2346 at ADOC0462894-95, without receiving a segregation preplacement screening, see generally Pls. Ex. 2304.
• A nursing record from September 3 reported that Abrams had suicidal thoughts and had told people he was going to hang himself. See id. at SPA_9559. Despite being suicidal, Abrams remained in segregation instead of being placed on suicide watch, see id. at SPA_9560, and did not receive a suicide risk assessment at that point, see Crook Apr. 2, 2019, Trial Tr. (doc. no. 2488) at 69.
• The segregation initial assessment conducted on September 4--several days after the seven-day timeframe in which it should have been completed--failed to mention that the day before, Abrams had told nursing staff that he was suicidal. See Pls. Ex. 2304 at SPA_9582-83.
• Records indicate that, while in segregation, space and security staff shortages prevented Abrams from having his scheduled mental-health appointments on November 20, 27, and 30, and December 4. See id. at SPA_9601; Joint Expert Case Summaries (doc. no. 2416-2) at 3.
• On approximately December 21, he was placed on suicide watch after stating that he was suicidal. See Pls. Ex. 2304 at SPA_9596, SPA_9599. Apparently, he had gone to the infirmary to have stab wounds checked on, and then felt increased anxiety about returning to a particular prison block. See id. A mental-health progress note from December 26 also reported that he had safety concerns and wanted to change institutions because of a conflict he had with gang-affiliated inmates due to his sexuality. See id. at SPA_9594. His records do not contain a single crisis treatment plan. See generally Pls. Ex. 2304.
• Abrams was released from suicide watch on December 26, see id. at SPA_9571, and sometime between then and January 2, he was placed in segregation, see Crook Apr. 2, 2019, Trial Tr. (doc. no. 2488) at 181; Defendants' Response to Amended Chart (doc. no. 2500-1) at 14. The records indicate that he did not receive a segregation preplacement screening. See Crook Apr. 2, 2019, Trial Tr. (doc. no. 2488) at 181-82; see generally Pls. Ex. 2304. Nor did he receive a three-day follow-up after being discharged from suicide watch. See generally Pls. Ex. 2304. The parties' experts noted that despite his stay on suicide watch, he was not placed on the mental-health caseload. See Joint Expert Case Summaries (doc. no. 2416-2) at 3; Pls. Ex. 2305 at SPA_9791.
• The segregation duty post logs indicate that, during the week running up to his suicide, there were several times where there was an hour, or even two hours, between security checks, see Vail Apr. 3, 2019, R.D. Trial Tr. at 149, even though ADOC policy requires that security checks in segregation be conducted every 30 minutes.
• On January 2, 2019, at approximately 7:00 p.m., more than an hour after the last security check, see id. , a correctional officer making a security check discovered Abrams hanging from a vent cover inside his cell, see Pls. Ex. 2307 at SPA_10451. At 7:11 a.m., he was cut down and medical staff initiated CPR, according to one officer's report. See id. at SPA_10452. According *1234 to both experts, this emergency response time was "inadequate to save life," as "11 minutes from discovery to cut down is more than enough time for death to occur." Joint Expert Case Summaries (doc. no. 2416-2) at 3.
• Drs. Burns and Perrien did not receive a medical review. See id. at 3. ADOC's quality improvement report stated that there were no areas for improvement in mental-health treatment or institutional operation, and recommended no corrective actions. See Pls. Ex. 2305 at SPA_9792-93. 6
Ryan Rust
On December 21, 2018, Ryan Rust was discovered in his segregation cell "sitting on [the] floor with one end of [a] belt around his neck and the other end tied to a bar in the window of the cell." Joint Expert Case Summaries (doc. no. 2416-2) at 2. His case illustrates ADOC's failures to complete follow-up appointments after a crisis placement and to conduct timely security checks in segregation in the immediate lead-up to a suicide. Specifically:
• Rust was placed on suicide watch from approximately November 5 to 16, 2018, see Pls Ex. 2298 at SPA_9880-81, but his records indicate that he did not receive any follow-up appointments after his release, see generally Pls. Ex. 2298.
• Rust attempted to escape and was returned to segregation on December 20 or 21. See id. at SPA_9869, SPA_9872; Joint Expert Case Summaries (doc. no. 2416-2) at 2. On December 21, shortly after his segregation placement, he was discovered hanging in his cell. See Joint Expert Case Summaries (doc. no. 2416-2) at 2.
• Prior to his death, Rust had received three separate segregation pre-placement screenings on December 20 and 21. See Pls. Ex. 2298 at SPA_9867-74. According to Drs. Burns and Perrien, the "reason for three pre-placement screenings was not clear. At best, the three completed screenings raise questions about inefficiencies in the system regarding redundant work and/or poor communication among nursing staff; at worst, they raise concerns regarding the authenticity and validity of the screenings." Joint Expert Case Summaries (doc. no. 2416-2) at 2. As Dr. Burns elaborated, in the worst-case scenario, it represented "an attempt to say that the screening was done when the screening wasn't done, and still very poorly coordinated because they did it three times." Burns Apr. 9, 2018, R.D. Trial Tr. at 190.
• Based on his review of the duty post logs, plaintiffs' expert Eldon Vail testified that about an hour passed from the last security check to the time Rust was discovered hanging. See Vail Apr. 3, 2019, R.D. Trial. Tr. at 151; see also Pls. Ex. 2662 at ADOC0469207 (duty post log indicating that more than an hour had passed).
• Drs. Burns and Perrien reported inadequate review of Rust's suicide. Specifically, they stated that they did not receive a medical review, and that the psychological autopsy was "limited" and did "not contain any psychological information." Joint Expert Case Summaries (doc. no. 2416-2) at 2. They did *1235 receive a document labeled only "Ryan Chas Rust," whose authorship and purpose was unclear, but did "identify deficiencies in mental health follow-ups, treatment planning and logistics." Id.
Kendall Chatter
On November 25, 2018, Kendall Chatter was discovered hanging from the ceiling of his cell in the temporary holding unit at Staton prison. ADOC's failures in his case include not transitioning him from acute to non-acute suicide watch prior to releasing him from suicide watch, not providing follow-up appointments after he was released from suicide watch, and not checking his cell even though he was intensely yelling and banging on his cell in the immediate lead-up to his suicide. Specifically:
• On November 16, 2018, Chatter cut his right wrist, possibly after being sexually assaulted. See Defs. Ex. 3577 at SPA_10176-81. He was placed on acute suicide watch that same day, see id. at SPA_10180, and then released directly to MHO the next day, without any intervening period on non-acute suicide watch, see id. at SPA_10178. He was released from MHO on November 20. See id. at SPA_10164; Joint Expert Case Summaries (doc. no. 2416-2) at 2.
• His records indicate that he did not receive three-or seven-day follow-ups after being released from suicide watch. Crook Apr. 2, 2019, Trial Tr. (doc. no. 2488) at 35. Director of Mental Health Services Crook said that the failures to do the follow-ups were violations of the interim agreement, but that she did not immediately discover the violations because no one in her office did a detailed review of his mental-health records until February 2019, more than two months after he died. See id. at 35-40.
• On November 25, Chatter loudly and intensely yelled and banged against his cell for a prolonged period of time. See Defs. Ex. 3577 at SPA_10200; Joint Expert Case Summaries (doc. no. 2416-2) at 2; Pls. Ex. 2401 at SPA_13483. The correctional shift supervisor instructed his officer to "just allow him to continue banging and being disruptive and he would get tired and stop," according to a written reprimand of the supervisor. Pls. Ex. 2401 at SPA_13483. Shortly after Chatter started making noise--according to one record, less than an hour later--a correctional officer distributing meals discovered him hanging from the ceiling by a sheet tied around his neck. See id. at SPA_10200-01.
• ADOC's review of the suicide was inadequate. No medical or security reviews were provided to Drs. Burns and Perrien. See Joint Expert Case Summaries (doc. no. 2416-2) at 2. Furthermore, according to the experts, the "mental health QI review contained little information and no recommendations for improvement in spite of failing to provide follow-up after watch placement and failure to provide an actual mental health assessment after referral from security 11/14/18.... The Psychological Autopsy states both that the treatment plan was up to date and included goals that were implemented but also states that there were no goals on the treatment plan because he wasn't on the mental health caseload." Id.
Mark Araujo
Mark Araujo used a sheet to hang himself from a door in his segregation cell at Limestone prison on November 23, 2018. Inadequacies in his case include not properly responding to his request for mental-health attention after he was placed in segregation, and not adequately reviewing his suicide. Specifically:
*1236 • On October 29, 2018, during his initial mental-health assessment following placement in segregation, Araujo requested to be placed on the mental-health caseload and begin medication. See Pls. Ex. 2291 at SPA_10221-22. Yet, according to Drs. Burns and Perrien, he was not seen by mental-health staff prior to his death almost a month later. See Joint Expert Case Summaries (doc. no. 2416-2) at 2.
• Drs. Burns and Perrien noted that the "QI review contains no recommendations" and that the psychological autopsy also "contained little information--and neglected to note that he wanted [mental-health] help and asked for it 10/29/18 when seen in seg[regation]." Id.
John Barker
John Barker hanged himself from a vent cover in his cell at St. Clair prison on September 26, 2018. Deficiencies in his case include housing him in segregation despite his serious mental illness (SMI), and inadequate interventions to save his life after he was discovered hanging. Specifically:
• Despite being flagged as having a SMI, major depressive disorder, see Pls. Ex. 1758 at SPA_3343-44, Barker had been housed in segregation for several months in the lead-up to his suicide, see Joint Expert Case Summaries (doc. no. 2416-2) at 1.
• On September 1, 2018, mental-health personnel recommended his administrative referral for removal from segregation due to his SMI diagnosis, see Pls. Ex. 1758 at SPA_3343-44, but records indicate that he was released from segregation on September 24, just two days before his suicide, see Joint Expert Case Summaries (doc. no. 2416-2) at 1. 7
• On September 26 at 6:30 p.m., a correctional officer observed Barker hanging from a vent cover over a toilet in his cell. See id. Troublingly, "[n]o actions [were] taken until 6:36 p.m. when medical [staff] arrived at which time [they] entered cell, cut prisoner down and began CPR." Id. Drs. Burns and Perrien concluded that the correctional officer response was inadequate because, as explained above, security officers "must intervene and begin life-sustaining efforts rather than waiting for medical," and also because the medical emergency response time of six minutes was inadequate. Id.
• Drs. Burns and Perrien did not receive security or medical reviews of the suicide, and the mental-health review "was cursory and found no problems and no areas for improvement." Id.
Ross Wolfinger
Ross Wolfinger was discovered hanging in his segregation cell at Fountain prison on August 22, 2018, less than a month after cutting his wrist and being placed in acute suicide watch. His case shows ADOC's failure to provide adequate treatment following release from suicide watch to segregation, the falsification of security logs and failure to conduct security checks in segregation in the time immediately leading up to his suicide, and the failure to initiate life-saving measures immediately when he was discovered. Specifically:
• Wolfinger's records state that on July 26, 2018, he was placed on acute suicide watch after attempting suicide by cutting his left wrist with a razor blade.
*1237 See Pls. Ex. 1823 at SPA_4134, SPA_4187-90. He remained on acute suicide watch until July 31, see id. at SPA_4167, when he was placed on nonacute suicide watch, id. at SPA_4153.
• On August 3, he was discharged from nonacute suicide watch to segregation. See Burns Dec. 7, 2018, Trial Tr. (doc. no. 2256) at 117; Pls. Ex. 1823 at SPA_4155, SPA_4163. The records indicate that he did not receive adequate follow-ups after his release from suicide watch. See Burns Dec. 7, 2018, Trial Tr. (doc. no. 2256) at 119; see generally Pls. Ex. 1823.
• According to Dr. Burns, Wolfinger's suicide risk was elevated by ADOC's failure to provide adequate treatment to him when he was returned to segregation. See Burns Dec. 7, 2018, Trial Tr. (doc. no. 2256) at 119.
• The night of Wolfinger's death, the correctional officer assigned to conduct security checks every 30 minutes in Wolfinger's area of segregation not only failed to do a single check, but also put false information in his duty post log indicating that he had completed the required checks, according to an ADOC memorandum discussing disciplinary action against the officer. See Pls. Ex. 2403 at SPA_13487. The memorandum states that the correctional officer's actions "resulted in" Wolfinger's death. Id. at SPA_13488.
• On August 22, around 1:00 a.m., Wolfinger was discovered hanging in his cell. See id. Drs. Burns and Perrien reported that the immediate intervention was inadequate: he was "discovered hanging at 12:57 a.m.," but "there was no intervention except to call for assistance which arrived at 1:03 a.m. No intervention until others arrived and then he was cut down and taken to HCU [the health care unit], arriving there at 1:08 a.m. LPNs attempted CPR and ambulance was called." Joint Expert Case Summaries (doc. no. 2416-2) at 2.
• Drs. Burns and Perrien also criticized the inadequate reviews of Wolfinger's suicide. No medical review was provided; the QI program review did not make any recommendations; the psychological autopsy provided no additional analysis or information. See id.
Jeffery Borden
On June 3, 2018, Jeffery Borden, who had been diagnosed with schizoaffective disorder, hanged himself on death row at Holman prison. See Pls. Ex. 1643 at ADOC0424844. His case is an example of ADOC failing to adequately intervene with potential life-saving measures and inadequately completing a suicide incident review. Specifically:
• Neither the correctional officers who originally found him hanging nor the nurse that later arrived at the scene attempted CPR or other life-saving efforts. See Joint Expert Case Summaries (doc. no. 2416-2) at 1; Pls. Ex. 1760 at SPA_2965.
• Drs. Burns and Perrien did not receive a medical or security review. See Joint Expert Case Summaries (doc. no. 2416-2) at 1.
Timothy Chumney
On May 12, 2018, "[w]ithin 1 day of being released from MHO to a housing unit where he expressed concern for his safety from other inmates," Timothy Chumney "was discovered hanging in his [segregation] cell having tied a bed sheet to a cell window and then around his neck." Id. ADOC's failures in his case include inadequate treatment planning, not placing him on suicide watch even though he was found to have a moderate risk of suicide, and an inadequate review of his suicide. Specifically:
*1238 • On May 7, 2018, Chumney was determined to be at a "moderate" risk for suicide, after telling medical staff that he had suicidal ideation at night and would rather harm himself than have someone else harm him. Pls. Ex. 1646 at ADOC0425086. That same day, however, he was admitted to MHO instead of suicide watch. See id. at ADOC0425042.
• On May 11, Chumney was discharged from MHO. See id. at ADOC0425011. The next day, at approximately 3:05 a.m., correctional officers conducting security rounds discovered him hanging from his segregation cell window in Limestone prison. See Pls. Ex. 1780 at SPA_3144; Joint Expert Case Summaries (doc. no. 2416-2) at 1.
• Dr. Burns and Perrien criticized that no "CPR, actual medical assessment or life-sustaining measures [were] attempted. LPN responding to the emergency said to leave him in the cell on the unit and called the physician to pronounce him dead. Hours later, the deputy coroner arrived and 'confirmed inmate Chumney deceased.' " Joint Expert Case Summaries (doc. no. 2416-2) at 1.
• ADOC also inadequately reviewed his suicide. Drs. Burns and Perrien did not receive medical or security reviews; the mental-health QI program review had no criticism or recommendation for anyone; the psychological autopsy revealed no additional or substantive information. See id.
• Drs. Burns and Perrien further criticized that there was "[n]o transitional care planned; treatment plan called only for a monthly contact with treatment coordinator and quarterly appointment with CRNP," and there was "[n]o plan to follow more closely (or intervene to prevent placement in [segregation] based on his anxiety and paranoia)." Id.
Robert Martinez
By the time Robert Martinez took his life on March 31, 2018, he had been in segregation at St. Clair prison for more than one year. Pls. Ex. 1493 at ADOC0420976-77. In his case, ADOC's failures included not conducting security rounds in segregation and not timely cutting him down when he was found hanging.
• Two weeks before his death, he told mental-health staff that he was "doing real bad" and needed to go to a psychiatric ward. Id. at ADOC0421023. ADOC left him in segregation and failed to connect him with mental-health staff.
• Correctional officers failed to conduct security checks in Martinez's unit for at least two hours during the morning of his suicide. See A.A. Apr. 23, 2018, R.D. Trial Tr. at 203-04.
• When ADOC staff discovered Martinez hanging from a sheet tied to a vent in his cell, they waited more than 30 minutes before cutting him down, a delay that, in the experts' words, was "inexcusable and inhumane." 8 Joint Expert Case Summaries (doc. no. 2416-2) at 1.
*1239 Billy Thornton
Billy Thornton died on March 2, 2018, as the result of a head injury he sustained when attempting to hang himself in segregation at Holman prison on February 26. See Joint Expert Case Summaries (doc. no. 2416-2) at 1; Stewart Apr. 23, 2018, Trial Tr. (doc. no. 1797) at 57. The failures by ADOC in his case include not placing him on suicide watch after he was found attempting to hang himself and said he wanted to kill himself, and not completing suicide risk assessments or providing follow-up appointments after releasing him from crisis watch.
• A nursing record from December 27, 2017 reports that Thornton said he wanted to kill himself, had been found attempting to hang himself, had suicidal thoughts, and auditory hallucinations of "kill, kill yourself." Pls. Ex. 1489 at ADOC0420855. Drs. Burns and Perrien testified that he should have been placed on suicide watch; however, the records show that he was improperly placed on MHO. See id. at ADOC0420856; Burns and Perrien Apr. 9, 2019, R.D. Trial Tr. at 89-90.
• The records indicate that no suicide risk assessment was conducted at the time. See Burns Apr. 9, 2019, R.D. Trial Tr. at 90; see generally Pls. Ex. 1489.
• Records indicate that he did not receive adequate follow-up appointments after release from MHO on January 2 or 3, 2018, given that he actually should have been placed on suicide watch rather than MHO. See Joint Expert Case Summaries (doc. no. 2416-2) at 1; Burns and Perrien Apr. 9, 2019, R.D. Trial Tr. at 121; Stewart Apr. 23, 2018, Trial Tr. (doc. no. 1797) at 50-52; see generally Pls. Ex. 1489.
• Thornton was again transferred to crisis watch on February 22, and then released back to segregation on February 23. See Stewart Apr. 23, 2018, Trial Tr. (doc. no. 1797) at 6-8. The records indicate that Thornton did not receive follow-up attention after his release from crisis watch. See Joint Expert Case Summaries (doc. no. 2416-2) at 1.
• On February 26, as a correctional officer was speaking to him in his segregation cell, Thornton "stepped onto his bed put a shoe string around his neck and was hanging from the light fixture," according to an incident report. Pls. Ex. 1488 at ADOC0421089. As the officer reached toward Thornton, the string broke, and Thornton fell and hit his head on the floor. See id.
• Officers put Thornton in a wheelchair and took him to the medical unit. See id. According to Drs. Burns and Perrien, the "decision to place him in wheelchair after sustaining head/neck injury rather than a back board and/or calling for medical to respond requires further review and supports need for additional and on-going first aid training for correctional staff." Joint Expert Case Summaries (doc. no. 2416-2) at 1.
• Thornton died on March 2 as a result of the head injury. See id. ; Stewart Apr. 23, 2018, Trial Tr. (doc. no. 1797) at 57; Pls. Ex. 1488 at ADOC0421089.
• ADOC's review of the incident leading to Thornton's death was inadequate. Drs. Burns and Perrien did not receive a medical or security review; and the mental-health QI review "did not identify any issues with mental health's failure to provide any follow-up to Mr. Thornton after crisis placements."
*1240 Joint Expert Case Summaries (doc. no. 2416-2) at 1.
• Ultimately, Dr. Burns testified that she believed ADOC's noncompliance with the interim agreement increased Thornton's risk of suicide, "because the risk was never measured and quantified, in spite of multiple crisis placements," and "there doesn't appear to be any effort to reduce that risk." Burns Dec. 7, 2019, Trial Tr. (doc. no. 2256) at 106.
Ben McClure
On December 30, 2017, Ben McClure jumped to his death from the top tier of a dormitory at Limestone prison. See Incident Report (doc. no. 1966-25) at 2; Pls. Ex. 1669 at ADOC0424820. ADOC failed to initiate immediate life-saving measures. Namely, the officers who found McClure did not immediately conduct CPR, but rather waited until Licensed Practice Nurses arrived a few minutes later, according to ADOC reports. See id. As stated above, Drs. Burns and Perrien emphasized that CPR should be initiated as soon as two security staff are present, regardless of whether medical staff has arrived. See Joint Expert Report and Recommendations (doc. no. 2416-1) at 29.
III. DISCUSSION
A. Permanent Injunction Requirements
The plaintiffs' emergency motion seeks permanent, albeit immediate, relief. To obtain a permanent injunction, plaintiffs must show: (1) actual success on the merits; (2) that irreparable injury will be suffered without an injunction; (3) that the threatened injury outweighs any damage the proposed injunction may cause the opposing party; and (4) that the injunction, if issued, would not be adverse to public interest. See Klay v. United Healthgroup, Inc. , 376 F.3d 1092 , 1097 (11th Cir. 2004). As discussed below, the plaintiffs meet all these requirements.
i. Success on the Merits: Eighth Amendment Violation
The plaintiffs satisfy the first requirement for a permanent injunction because they have succeeded on the merits of their claim. To prevail on an Eighth Amendment challenge, plaintiffs must show that: (1) objectively, prisoners had serious medical needs and either had already been harmed or were subject to a substantial risk of serious harm; and (2) subjectively, the defendants acted with deliberate indifference to that harm or risk of harm; that is, they knew and disregarded an excessive risk to inmate health or safety. See Braggs , 257 F. Supp. 3d at 1189 . As the court held in 2017, the plaintiffs met this standard and therefore established an Eighth Amendment violation, given that ADOC's mental-health care for prisoners was, "[s]imply put, ... horrendously inadequate" Braggs , 257 F. Supp. 3d at 1267 .
The court specifically found that ADOC's inadequate suicide prevention contributed to the Eighth Amendment violation. As the court explained, deficient suicide prevention--both alone and in combination with six other inadequacies--"subject[s] mentally ill prisoners to actual harm and a substantial risk of serious harm." Id. at 1193 . ADOC's suicide prevention was found to be deficient in multiple ways. These included inadequately identifying prisoners at risk of suicide, providing inadequate treatment and monitoring to at-risk prisoners, as well as inappropriately releasing prisoners from suicide watch and not giving them follow-up care. See id. at 1220, 1231 . Additionally, the court found that the "skyrocketing number of suicides within ADOC, the majority of which occurred in segregation," reflected the "combined *1241 effect" of inadequate screening for the impact of segregation on mental health, and inadequate treatment and monitoring in segregation units. Id. at 1245 .
As extensively detailed in the liability opinion, see id. at 1194-1200 , ADOC's "persistent and severe shortages" of mental-health and correctional staff significantly contributed to all these deficiencies. Id. at 1268 . Since then, the court has repeatedly reaffirmed the centrality of mental-health and correctional understaffing to ADOC's mental-health care failings, and thus, Eighth Amendment violations. See Braggs , 2019 WL 539050 , 367 F. Supp. 3d 1340 at *5, 9-10 ; Braggs v. Dunn , 2019 WL 78949 , 382 F. Supp. 3d 1267 at *1 (M.D. Ala. Jan. 2, 2019) (Thompson, J.); Braggs v. Dunn , 2018 WL 5410915 , at *1 (M.D. Ala. Oct. 29, 2018) (Thompson, J.).
Now, in addition to the liability findings, the court further finds that the substantial and pervasive deficiencies identified in the 15 recent suicides demonstrate that ADOC's suicide-prevention efforts remain inadequate and continue to contribute to the ongoing Eighth Amendment violation originally found in the liability opinion. ADOC still has serious deficiencies in the identification of prisoners at risk of suicide, as well as in their treatment, monitoring, and follow-up care. The deficiencies include:
• Failing to place suicidal prisoners on suicide watch;
• Failing to conduct suicide risk assessments;
• Failing to appropriately monitor prisoners on suicide watch;
• Failing to put prisoners on the mental-health caseload when appropriate;
• Inadequate treatment planning; and
• Inadequate follow-up treatment after release from suicide watch.
ADOC's segregation practices also continue to suffer from the serious flaws the court found in the 2017 liability opinion, including:
• Inadequate screening of prisoners for suicidality and SMIs prior to placing them in segregation;
• Placing prisoners with SMIs in segregation absent extenuating circumstances; 9 and
• Failing to conduct 30-minute security checks in segregation, and failing to make sure the checks are staggered.
Given these serious inadequacies in segregation practices, it is unsurprising that, similar to the liability opinion's finding in June 2017 that the "majority" of suicides occurred in segregation, Braggs , 257 F. Supp. 3d at 1245 , ADOC recognized nearly two years later, in March 2019, that the "majority of inmates who committed suicide within ADOC have been men who were alone in a restrictive housing cell, 10 after being released from suicide watch." Pls. Ex. 2706 (Mar. 21, 2019, Daniels's memorandum announcing directive).
These continuing deficiencies are compounded by ADOC's repeated failure to initiate immediate life-saving measures. Although not identified in the liability opinion, this problem clearly exacerbates ADOC's inadequate suicide-prevention efforts, and illustrates that prisoners remain at substantial risk of serious harm.
*1242 Critically, mental-health and correctional understaffing remains a driving force behind the suicide-prevention deficiencies putting prisons at risk. As of December 2018, ADOC reported that 62 % of correctional officer positions were vacant, see March 2019 Quarterly Staffing Report (doc no. 2386-1) at 3, and as of September 2018, 23.6 % of the mental-health positions were vacant, see December 2018 Quarterly Staffing Report (doc. no. 2378-1) at 9. Commissioner Dunn admitted that ADOC is currently "struggling" to comply with court orders because of inadequate staffing levels, Dunn Apr. 1, 2019, R.D. Trial Tr. at 145, and affirmed that understaffing remains one of the problems driving the spike in suicides. See id. at 154-55.
In addition to showing that prisoners remain at a substantial risk of serious harm, the 15 suicides also demonstrate that ADOC continues to act with deliberate indifference. As found in the liability opinion, "the state of the mental-health care system is itself evidence of ADOC's disregard of harm and risk of harm: in spite of ... notice of the actual harm and substantial risks of serious harm posed by the identified inadequacies in mental-health care, those inadequacies have persisted for years and years." Braggs , 257 F. Supp. 3d at 1256 . Almost two years since the court wrote those words, the inadequacies continue to persist, as evidenced by the problems pervading the recent suicides.
Furthermore, many of the inadequacies in the 15 suicides constitute noncompliance with the interim agreement and other remedial orders that ADOC agreed to implement. ADOC's continued inability to carry out the terms of the interim agreement and other remedial measures thus far illustrates "a striking indifference by ADOC to a substantial risk of serious harm." Id. at 1264 .
Finally, ADOC's inadequate internal review of the 15 suicides shows ongoing deliberate indifference, just like the court originally found deliberate indifference in part because ADOC had "done vanishingly little to exercise oversight of the provision" of mental-health care. Id. at 1257 . ADOC's ongoing broader failures to self-monitor are also extensively detailed in the monitoring section below.
ADOC has recently adopted some promising measures to improve suicide prevention, such as the March 21, 2019, announcement by ADOC Deputy Commissioner Charles Daniels of a directive generally prohibiting the release of inmates from suicide watch directly to segregation. See Pls. Ex. 2706. However, as elaborated below, the measures are insufficient to address the scope of a problem that is many years in the making, and, as they were implemented quite recently, it remains to be seen whether they will even be effectively implemented. In any case, several of the key measures came only after the spike in suicides had taken more than a dozen lives, and after the plaintiffs brought attention the problem by requesting emergency relief. Put differently, the measures have been too little, too late.
To conclude, while the liability findings by themselves would justify the relief ordered here, the court's additional factual findings concerning inadequate suicide prevention in the 15 recent suicides underscores that the constitutional violation remains ongoing and requires immediate relief. Accordingly, the plaintiffs satisfy the first requirement for a permanent injunction.
With this in mind, the court will now briefly discuss why the plaintiffs satisfy the remaining requirements for a permanent injunction.
*1243 ii. Remaining Permanent Injunction Requirements
The plaintiffs meet the remaining three requirements for a permanent injunction. As to the second requirement, the immediate and substantial risk of suicide, as reflected in the recent wave of suicides, satisfies the irreparable harm inquiry. As to the third, the threatened injury absent an injunction--a higher risk of suicides and suffering--outweighs any harm the injunction would cause, particularly because, as discussed below, the defendants agree with or claim to be already enacting most of the measures the plaintiffs seek. Finally, an injunction is not adverse to the public interest, for "the public interest is served when constitutional rights are protected." Democratic Exec. Comm. of Fla. v. Lee , 915 F.3d 1312 , 1327 (11th Cir. 2019).
B. The Defendants' Arguments Against Relief
i. The Defendants' Notice Argument
The defendants contend that any relief based on provisions of the interim agreement would exceed the scope of the evidentiary hearing on this matter, because they did not have the opportunity to present evidence on the interim agreement at the hearing. See Defendants' Response to Plaintiffs' Proposed Opinion and Order (doc. no. 2499) at 13-17. The court rejects this argument. The defendants had adequate notice as to the scope of the requested immediate relief: In the plaintiffs' pretrial brief, the interim agreement was among the provisions that they requested be immediately implemented. See Plaintiffs' Pretrial Brief (doc. no. 2435) at 15 (requesting entry of an order for the relief provided in the Interim Order as "immediate permanent relief"). The defendants also had an opportunity to cross Dr. Burns on the interim agreement.
Nevertheless, the court recognizes that the defendants likely were confused as to this issue. During the discussion about restricting the trial to immediate relief, it was not specifically mentioned that the interim agreement was encompassed in the immediate relief the court would be considering, and defense counsel seemed to be focused on the supplemental recommendations. Furthermore, the defendants' lead attorney was out sick at the time of the discussion, and his associate may not have realized that the immediate relief requested by the plaintiffs encompassed the interim agreement.
Because there is an urgent need for immediate relief, and because the defendants previously agreed to the terms of the interim agreement, the court will issue an order for relief today that includes many of the agreement's provisions. However, if the defendants disagree with the parts of the order addressing the interim agreement and would like another opportunity to present evidence about it, the court will consider their evidence and modify or vacate the relevant portions of this opinion and order if appropriate.
ii. The Defendants' Arguments on Mootness and Ongoing and Continuous Violation
The defendants argue that steps they have taken since the start of the litigation to improve suicide prevention render unnecessary many, if not all, aspects of the relief the plaintiffs request. They frame this argument in several ways. First, they contend that their remedial actions mean that certain requested provisions would fail to meet the requirement of an "ongoing and continuous" violation, Summit Med. Assocs., P.C. v. Pryor , 180 F.3d 1326 , 1337 (11th Cir. 1999), a phrase drawn from caselaw on the Ex parte Young exception to Eleventh Amendment immunity, see 209 U.S. 123 , 28 S.Ct. 441 , 52 L.Ed. 714 (1908).
*1244 Second, they contend that claims to certain requested relief are moot because they voluntarily ceased the offending conduct. 11
As to the first argument, the defendants rely on the statement in Summit that the Ex parte Young exception "applies only to ongoing and continuous violations of federal law." 180 F.3d at 1337 . The plaintiffs in Summit sought to enjoin the enforcement of a criminal law, but the defendants argued that the case should be dismissed because there was no ongoing and continuous violation. The court rejected that argument, explaining that "[t]he ongoing and continuous requirement merely distinguishes between cases where the relief sought is prospective in nature, i.e. , designed to prevent injury that will occur in the future, and cases where relief is retrospective." Id. at 1338 . The court further opined that the requirement for ongoing and continuous violations is satisfied "where there is a threat of future enforcement [of the law] that may be remedied by prospective relief." Id. Applying that reasoning to the case at hand, the court must answer the question whether the plaintiffs face a threat of being subjected in the future to the challenged prison conditions that may be remedied by prospective relief. As shown by the earlier discussion of the court's findings, and as detailed below, the court finds that there is a continuing threat of the plaintiffs being subjected in the future to the challenged prison conditions and that this continuing threat may be remedied by prospective relief.
As to their second argument, the defendants cite three cases to support their contention that their remedial actions have mooted certain requested relief. First, the defendants cite County of Los Angeles v. Davis , where the Supreme Court reiterated that, "as a general rule, voluntary cessation of allegedly illegal conduct does ... not make the case moot." 440 U.S. 625 , 631, 99 S.Ct. 1379 , 59 L.Ed.2d 642 (1979) (internal quotation marks omitted). The Court explained that a case may become moot if two conditions are met: "(1) it can be said with assurance that there is no reasonable expectation ... that the alleged violation will recur ..., and (2) interim relief or events have completely and irrevocably eradicated the effects of the alleged violation." Id. (internal quotation marks omitted).
The defendants also cite two subsequent Eleventh Circuit cases explaining--with respect to voluntary cessation--that when the defendant is a government actor rather than a private citizen, "there is a rebuttable presumption that the objectionable behavior will not recur." Troiano v. Supervisor of Elections in Palm Beach Cty., Fla. , 382 F.3d 1276 , 1283 (11th Cir. 2004) (citing Coral Springs St. Sys., Inc. v. City of Sunrise , 371 F.3d 1320 , 1328-29 (11th Cir. 2004) ). Troiano involved a lawsuit for injunctive relief to address a county's alleged failure to make auxiliary audio devices available in voting booths. See id. at 1278 . The court held that the case was moot based on the defendant's voluntary installation *1245 of the audio devices in all precincts and strong evidence that they would be available in all future elections, including the fact that the defendant ended the allegedly illegal practice prior to receiving notice of the litigation. See id. at 1285-86 . Coral Springs involved a challenge to an allegedly unconstitutional city ordinance. See 371 F.3d at 1323 -24 . There, the court clarified that the repeal of an ordinance moots a challenge to it unless the court finds that it is "reasonably likely" to be reenacted or it is replaced with another constitutionally suspect law. 371 F.3d at 1330 , 1331 n.9.
Taken together, these mootness cases stand for the following propositions. A claim may become moot through voluntary cessation only if there is no reasonable expectation that the alleged violation will recur, and interim relief or events have completely and irrevocably eradicated the effects of the alleged violation. If the defendant is a governmental actor, and the defendant has eliminated the challenged conduct or law, that defendant is entitled to a rebuttable presumption that the conduct or law will not recur.
Two Eleventh Circuit cases not cited by the defendants specifically address the issue of when injunctions targeting Eighth Amendment violations become unnecessary due to a prison system's remedial efforts. See Thomas v. Bryant , 614 F.3d 1288 (11th Cir. 2010) ; LaMarca v. Turner , 995 F.2d 1526 (11th Cir. 1993). In these cases, the defendants argued that injunctive relief was unnecessary because they had taken steps to address the challenged condition or practice by the time of trial. Faced with these arguments, the courts "recognized that '[s]ubsequent events, such as improvements in the allegedly infirm conditions of confinement, while potentially relevant, are not determinative' of whether injunctive relief is no longer warranted." Thomas , 614 F.3d at 1320 (quoting LaMarca , 995 F.2d at 1541 ). 12 The Eleventh Circuit opined that, when defendants attempt to avoid injunctions based on changes they made after a suit started, they "must satisfy the heavy burden of establishing that these such events 'have completely and irrevocably eradicated the effects of the alleged violations.' " Id. (quoting LaMarca , 995 F.2d at 1542 ); compare Cty. of Los Angeles , 440 U.S. at 631 , 99 S.Ct. 1379 (reciting same standard). Applying that heavy burden in Thomas , for example, the court held that, "[a]lthough DOC's recent reforms may represent affirmative responses to recognized deficiencies in its ability to address the needs of its growing mentally ill inmate population, the defendants have not established that they have eradicated the effects of the constitutional violations found by the district court." Id. at 1321 (internal citations omitted).
Applying these precepts, the court holds that the plaintiffs' claims for relief are not moot. As elaborated below, unlike in the cases cited by the defendants, it is not clear here that the challenged practices have ceased; in other words, the defendants have not satisfied their "heavy burden" of establishing that the steps they *1246 have taken have "completely and irrevocably eradicated the effects of the alleged violations." Thomas , 614 F.3d at 1321 (quoting LaMarca , 995 F.2d at 1542 ); see also Cty. of Los Angeles , 440 U.S. at 631 , 99 S.Ct. 1379 . Because the practices have not ceased, the defendants are not entitled to a rebuttable presumption that those practices will not recur. However, even if the court were to conclude that the unconstitutional conditions had ceased, and the rebuttable presumption therefore applied, the court would still find that it is reasonably likely that those conditions will recur. The voluminous evidence of ADOC's repeated failures to comply with its own policies and the court's orders, and of ADOC's lack of substantial progress in addressing its severe understaffing problem--which lies at the root of its inadequate suicide-prevention measures--overcomes the "rebuttable presumption that the objectionable behavior will not recur." Troiano , 382 F.3d at 1283 .
Throughout this case and in the suicide-prevention trial, the court has seen time and again compelling evidence of ADOC's inability to ensure that its ground-level staff comply with directives from the top, not to mention with the orders of this court. In the suicide-prevention trial, the court saw ample evidence that the noncompliance continues, as demonstrated by the circumstances surrounding the recent suicides. The history of this case is replete with evidence of directives given and corrective action plans created that have been doomed to irrelevance because of a lack of follow-through to ensure the directives were obeyed and the plans put into action. The heart of the matter is understaffing--the overriding problem that makes all of ADOC's other problems so difficult to solve. Without sufficient staff, ADOC will continue to have great difficulty both with carrying out all of the changes it needs to make, and with adequately supervising its staff's compliance with its directives.
The court now turns to the defendants' specific mootness and Ex parte Young -based challenges to Drs. Burns and Perrien's immediate relief recommendations.
1. The Defendants' Efforts to Eliminate Improper Use of Mental-Health Observation
The defendants argue that it is unnecessary for the court to include in its remedial order the experts' recommendation that mental-health observation (MHO) not be used as a part of suicide prevention, because there is no ongoing and continuous violation of federal law to address, and because ADOC and Wexford voluntarily ceased the practice. See Defendants' Response to Plaintiffs' Proposed Opinion and Order (doc. no. 2499) at 18-21. They argue that ADOC policy does not authorize the use of MHO for suicidal prisoners and that the policy is being revised to make this clearer; that they have expressed concern about the issue with their vendor and the vendor has taken action; and that some data indicates that the use of MHO for suicide watch is declining. See id. They also point to testimony they contend shows that the use of MHO for suicide watch has ended.
ADOC's actions, while commendable, are insufficient to show that the use of MHO for suicidal inmates has been completely and irrevocably eradicated. Furthermore, the court finds that, even if the use of MHO for suicidal inmates has abated to some extent, there is still a significant threat--and it is reasonably likely--that the dangerous practice will continue.
First, the testimony as to whether MHO has stopped being used for suicidal prisoners is far from conclusive. On February 15, 2019, Crook wrote a letter to Wexford, ADOC's vendor, notifying it of the improper use of MHO, among other "systemic failures to comply with court orders." Pls. Ex. 2710 at ADOC0475738. Crook testified *1247 that, since sending the letter, she has not received any reports suggesting that MHO is being used for suicidal inmates. See Crook Apr. 4, 2019, Trial Tr. (doc. no. 2487) at 34. However, it is not clear that she would receive such reports if this were happening. Crook also testified to seeing an increase in the number of people in acute suicide watch and a decrease in those in MHO. See id. at 33. She concluded from those numbers "that MHO is being utilized less as a first placement for crisis cell." Id. at 34 (emphasis added). Notably, she stopped short of saying the practice had ended. The defendants also point to ADOC Psychiatry Director Kern's belief that MHO is no longer being used for suicide watch. See Kern Mar. 29, 2019, Trial Tr. (doc. no. 2483) at 112. But the court does not credit this testimony because the only basis he provided for it was his and his colleagues' verbal communications with Wexford personnel. See id. at 112-16. Kern admitted that, in spite of the seriousness of the matter, he had not verified his belief by looking at the appropriate logs. See id. at 113. Although Wexford's Program Director for Mental Health Barbara Coe testified that her company would not put suicidal prisoners on MHO, see Coe Apr. 4, 2019, R.D. Trial Tr. at 199, the court cannot rely on her promise, particularly when Wexford was not supposed to be using MHO in that way in the first place, see LaMarca , 995 F.2d at 1542 ("[D]efendants must offer more than their mere profession that the conduct has ceased and will not be revived.").
The defendants argue that Wexford has implemented a formal corrective action plan regarding the misuse of MHO. See Defendants' Response to Plaintiffs' Proposed Opinion and Order (doc. no. 2499) at 19. Yet, the corrective action plan the defendants submitted as evidence does not even mention MHO. See Defs. Ex. 3657 at ADOC0475742-46 (Wexford Suicide Prevention Corrective Action Plan, Initiated January 17, 2019). Crook testified that to fix the MHO problem identified in her letter, Wexford has "given an absolute directive to [its] staff that people will no longer be on MHO if they are declaring suicidality." Crook, Apr. 3, 2019, Trial Tr. (doc. no. 2486) at 51. But she also testified that she had not seen a copy of Wexford's directive. See id. at 52. More generally, Crook admitted that she has insufficient staff to keep up with all of the monitoring of court orders that ADOC needs to do. See id. at 68-69; Crook Apr. 1, 2019, Trial Tr. (doc. no. 2485) at 11-12. Thus, the court cannot conclude at this time that she will be able to ensure compliance with the directive.
Finally, the court rejects the defendants' argument that there is no longer a violation because their policy does not authorize the use of MHO for suicidal prisoners. Crook testified that ADOC's policy prohibiting the use of MHO for suicidal prisoners has been in place since 2005. See Crook Apr. 4, 2019, Trial Tr. (doc. no. 2487) at 32-33. As ADOC's repeated and admitted placement of suicidal prisons on MHO shows, however, the existence of that policy did nothing to stop the practice. While Dr. Kern testified that ADOC is currently updating the policy to make it clearer that MHO should not be used for suicide watch, he said the update was not yet finalized. See Kern Mar. 29, 2019, Trial Tr. (doc. no. 2483) at 108-09. Even after the updated policy is finalized, it will provide little assurance that the practice will not recur: Noncompliance with ADOC policy has been a recurring theme for MHO use and other areas throughout this case, as shown in many of the suicides discussed above.
In sum, the court concludes that there is a continued significant threat of placement of suicidal inmates in MHO that could be remedied by injunctive relief; that the defendants have not established that they have eradicated the effects of the constitutional *1248 violations found by the court; and that to the extent ADOC's recent remedial efforts have eliminated the use of MHO for suicidal prisoners, it is reasonably likely that those conditions will recur. Therefore, the requested relief is not moot.
2. The Defendants' Efforts to Eliminate Transfers from Suicide Watch to Segregation
In a March 21, 2019, memorandum, ADOC Deputy Commissioner of Operations Daniels announced a directive prohibiting the transfer of prisoners from suicide watch to segregation "unless there is no alternative due to well-documented exceptional circumstances or exigent circumstances arising from an inmate's behavior." Pls. Ex. 2706. The memorandum states that, if an inmate cannot be safely discharged to a unit other than segregation, Daniels or his designee must approve the temporary segregation placement. See id. The defendants argue that this directive moots and renders unnecessary the entry of a remedial order enforcing the experts' recommendations regarding prisoners in segregation who have been placed on suicide watch.
While promising, the memorandum announcing the directive is insufficient evidence that ADOC has completely and irrevocably eradicated the practices addressed by the experts' recommendation, or that the practices will not recur. If followed , the directive could largely address the experts' recommendation on this issue. But it is too soon to tell how well it will be followed: Daniels issued the memorandum just a week before the start of the suicide-prevention trial. The defendants will need to present evidence of sustained compliance with the directive over a longer period of time to convince the court that ADOC has successfully ended the practice. 13
Moreover, as stated earlier, this case is replete with examples of directives and policies being issued but not followed. So long as the correctional understaffing problem continues, measuring and ensuring compliance with directives will remain difficult for ADOC. In addition, the continuing severe correctional staffing shortage creates pressure to use segregation for potentially violent prisoners. Without adequate correctional staffing, fights and misconduct will continue unabated, and segregation will continue to be the first option for managing such prisoners. See Vail Dec. 22, 2016, Trial Tr. (doc. no. 1207) at 81, 90 (discussing how overcrowding and understaffing lead to more violence and misconduct, creating a higher need for segregation; and testifying that segregation is "the typical prison response" to violence and misconduct).
In sum, the court is not at all convinced that the directive has succeeded in eliminating the problem it seeks to address, and finds that the problem is reasonably likely to recur. 14
*1249 3. Training for Nursing Staff
The defendants contend that the court should not enter an order on the experts' recommendation to train all nursing staff on how to complete segregation pre-placement screenings. See Immediate Relief Recommendations (doc. no. 2416-4) at 3. While the defendants do not object to the experts' recommendation, they argue that they are already providing comprehensive training to nurses conducting pre-placement screenings, and that a previously issued remedial order already requires such training. See Defendants' Response to Plaintiffs' Proposed Opinion and Order (doc. no. 2499) at 39-40. They also assert that they issued a new policy in December 2018 on segregation pre-placement screenings that contains detailed instructions. See id. at 40. Accordingly, they contend, there is no ongoing constitutional violation in this area. See id. The court disagrees.
As discussed above, the Ex parte Young analysis looks at whether there is a threat of future harm from the challenged prison conditions that may be remedied by prospective relief. The answer here is clearly yes. The parties' experts undertook an extensive and thorough investigation of the state of suicide prevention in ADOC, looking at thousands of documents, touring four facilities, and interviewing prisoners as well as ADOC and Wexford staff. See Joint Expert Report and Recommendations (doc. no. 2416-1) at 4. Based on their study, they concluded that training for nurses assessing prisoners going into segregation is insufficient. Specifically, they found that training "should provide greater detail about indicators to look for as well as include how to place someone on immediate watch after hours and how to initiate an emergent referral." Immediate Relief Recommendations (doc. no. 2416-4) at 3. Nurses should be trained on an "easy in" model, meaning that, if a nurse is "uncertain in any way about a case, the inmate is placed on watch." Id. The existing remedial order does not address these issues; it simply says that nurses shall be "trained in the screening process." Order and Injunction on Segregation Remedy (doc. no. 1815-1) at 2.
Moreover, Drs. Burns and Perrien's findings about ADOC's deficient preplacement screenings show that, well after the 2017 liability opinion and 2018 segregation remedy order, nurses still are not well-trained enough to adequately screen inmates. See Joint Expert Report and Recommendations (doc. no. 2416 1) at 14-15 (finding "[n]o instances of prisoners being diverted from [segregation] or placed on watch as a result of pre-placement screening ... despite multiple subsequent placements on suicide watch and mental health observation from [segregation]"). Perhaps most notably, the fact--recognized by ADOC--that the majority of suicides by prisoners in its custody are men released from suicide watch into segregation is compelling circumstantial evidence that nurses need to be better trained in screening inmates before they are placed in segregation. See Pls. Ex. 2706 (Mar. 21, 2019, Daniels's memorandum announcing directive). For example, Matthew Holmes killed himself within roughly 12 hours of being placed in segregation, after ADOC "fail[ed] to generate an emergency referral to mental health in response to a positive pre-placement screen." Joint Expert Case Summaries (doc. no. 2416-2) at 4.
Finally, while the defendants note that they have promulgated a new policy on preplacement screening, the policy they cited nowhere references any required training. See Defs. Ex. 3647. Even if it did, the record has repeatedly shown that ADOC's enactment of a policy often does not translate to ground-level compliance.
In sum, the court concludes that there remains a significant threat of nurses conducting *1250 inadequate pre-placement screening of prisoners going into segregation, and that injunctive relief could remedy this threat.
4. Security Checks in Segregation
The defendants argue that the court should not enter an order implementing the experts' recommendation that "30-minute custody rounds in segregation must be enforced consistent with existing policy," Immediate Relief Recommendations (doc. no. 2416-4) at 4, because the plaintiffs failed to show an ongoing constitutional violation regarding security checks in segregation, see Defendants' Response to Plaintiffs' Proposed Order and Opinion (doc. no. 2499) at 40. The court disagrees. 15
An ongoing and continuous violation exists for purposes of Ex parte Young when there is a threat of future harm from the challenged prison condition that may be remedied by prospective relief. As discussed earlier, the court has found, based on the evidence at the suicide-prevention trial, that inadequate monitoring of prisoners in segregation continues to be a substantial problem in ADOC, so there is a threat of future harm.
To support their ongoing-violation argument, the defendants point to their existing policy requiring 30-minute checks on prisoners in segregation, see Pls. Ex. 1399, which, they note, the plaintiffs' experts agree is an appropriate policy, see Vail Apr. 3, 2019, R.D. Trial. Tr. at 141; Burns Apr. 9, 2019, R.D. Trial Tr. at 37-38. However, as the evidence has shown, like other policies in ADOC, the existence of the 30-minute policy does not mean that it will be followed. 16 Indeed, the whole purpose of the experts' recommendation is that the policy be enforced.
The defendants also cite evidence presented at the suicide-prevention trial that several wardens and their staff have taken steps to ensure that 30-minute checks are regularly conducted in their facilities, and that certain discovered violations have been corrected. This evidence falls short of establishing that ADOC has "completely and irrevocably eradicated the effects of the alleged violations," let alone that there not a serious threat of the problem recurring. Thomas , 614 F.3d at 1321 . While it is undeniably important that wardens take appropriate disciplinary action when they discover violations, the evidence did not convince the court that ADOC is catching most violations. Instead, the court came away convinced that ADOC's confirmation of compliance remains insufficient. At the suicide-prevention trial, the court heard ample evidence of substantial and pervasive problems in complying with the policy *1251 to conduct security checks every 30 minutes. For example, plaintiffs' expert Vail testified that, based on the segregation duty post logs that he has reviewed, ADOC has not demonstrated a consistent and sustained practice of conducting 30-minute security checks. See Vail Apr. 3, 2019, R.D. Trial Tr. at 156. He said that of the six or seven facilities he reviewed, only one "passed muster." Id. Most troublingly, the logs from Holman prison showed two entire (eight-or 12-hour) shifts in which not a single security check was logged, and other days in which more than two hours passed before a security check was logged. See id. at 155.
Finally, given the continuing correctional understaffing, the court finds that inadequate checks are likely to be a recurring problem. See Perrien Apr. 9, 2019, R.D. Trial Tr. at 195 (testifying that it is her understanding that ADOC is unsure whether it can follow its own segregation-rounds policy in "particularly understaffed facilities"). The evidence fell far short of showing that the problem of inadequate security checks had been eradicated, that the problem poses no threat of future harm to the plaintiffs, or that ADOC has developed a functional system for ensuring that such checks occur in all segregation units. As explained above, substantial and pervasive inadequacies identified by the court remain that may be remedied by injunctive relief.
C. The Prison Litigation Reform Act
Under the Prison Litigation Reform Act (PLRA), a court cannot order prospective relief addressing prison conditions unless it "finds that such relief is narrowly drawn, extends no further than necessary to correct the violation of the Federal right, and is the least intrusive means necessary to correct the violation of the Federal right." 18 U.S.C. § 3626 (a)(1)(A). Whether the relief meets the PLRA's "need-narrowness-intrusiveness" requirement is "determined with reference to the constitutional violations established by the specific plaintiffs before the court." Brown v. Plata , 563 U.S. 493 , 531, 131 S.Ct. 1910 , 179 L.Ed.2d 969 (2011). In making the determination, courts are required to "give substantial weight to any adverse impact on public safety or the operation of a criminal justice system." 18 U.S.C. § 3626 (a)(1)(A). 17
For the following reasons, and based on a comprehensive review of the record, 18 the court concludes that virtually all of the immediate suicide-prevention relief requested here satisfies the PLRA's need-narrowness-intrusiveness requirement. Severe inadequacies in ADOC's suicide-prevention efforts contribute to the ongoing Eighth Amendment violation that the court originally found in the liability opinion, and reaffirms today. The relief ordered is narrowly tailored to address these inadequacies, which relate to, among other *1252 areas, identifying inmates at risk of suicide, treating and monitoring them, and providing them follow-up care. Furthermore, as elaborated below, not only do the opinions of both parties' experts support the need for the relief, but the defendants themselves have at least agreed, or not objected, to many of the relief's provisions, and in some instances have themselves suggested the relief. See Interim Agreement (doc. no. 1106-1); Defendants' Response to Plaintiffs' Proposed Opinion and Order (doc. no. 2499) at 13.
i. Particularized Findings
As required by the Eleventh Circuit Court of Appeals, the court will make "particularized findings, on a provision-by-provision basis, that each requirement imposed" here meets the PLRA's need-narrowness-intrusiveness requirement. Cason v. Seckinger , 231 F.3d 777 , 785 (11th Cir. 2000) ; see also United States v. Sec'y, Fla. Dept. of Corrs. , No. 12-22958-CIV, 2015 WL 4768247 at *1 (S.D. Fla. Aug. 12, 2015) (Seitz, J.) (interpreting Cason 's application of the "need-narrowness-intrusiveness" requirement to termination proceedings of consent decrees as requiring "a district court to make particularized findings as to each element" of injunctive relief). In discussing the evidence that supports these findings, the court's analysis will largely focus on a single inquiry: is the provision necessary to correct the constitutional violation established by the plaintiffs? This is for both practical and logical reasons. Logically speaking, if the court determines the relief is necessary to correct the violation found by the court, it follows that the relief is (1) "narrowly drawn," (2) "extends no further than necessary," and (3) "is the least intrusive means necessary to correct the violation." 18 U.S.C. § 3626 (a)(1)(A). 19 Relatedly, and practically speaking, because the three components of the requirement (need, narrowness, intrusiveness) really blend into a single inquiry, evidence showing compliance with one component often also shows compliance with the others. It would make for an excessively redundant and lengthy (more so than it already is) opinion to analyze each component separately and thus frequently repeat the same evidence for why it is satisfied, especially given the redundancy already created by the requirement for provision-by-provision findings.
ii. The Interim Agreement
The genesis of the interim agreement traces back to the suicide of Jaime Wallace, a plaintiff class member who had severe mental illnesses, as well as intellectual and physical disabilities. See Braggs , 257 F. Supp. 3d. at 1184 . At the liability trial, he recounted the many times he had tried to kill himself, showed the scars on his arms where he made repeated attempts, and told the court that he had not received enough treatment for his illnesses. Ten days after testifying, he hanged himself in prison and died. Wallace's suicide prompted the court to halt proceedings and allow the parties to mediate immediate, interim measures to prevent future suicides. The parties reached *1253 the interim agreement, which the court adopted as an interim order. See Interim Agreement and Order (doc. nos. 1106, 1106-1).
For the following reasons the court now finds that the vast majority of the terms of the interim agreement--as modified by Drs. Burns and Perrien's recommendations--are narrowly drawn, extend no further than necessary to correct the defendants' constitutional violation, and are the least intrusive means necessary to correct the violation. In making this finding, the court gives "substantial weight to any adverse impact on public safety or the operation of a criminal justice system caused by the relief." 18 U.S.C. § 3626 (a)(1)(A).
The court will next make particularized findings for each provision, but three overarching reasons in support of the PLRA findings bear emphasizing at the outset. First, where, as here, the provisions of relief ordered by a court are adopted from an agreement jointly drafted and reached by the parties, it is compelling evidence that the provisions comply with the needs-narrowness-intrusiveness criteria. See Morales Feliciano v. Calderon Serra , 300 F. Supp. 2d 321 , 334 (D.P.R. 2004) (Perez-Gimenez, J.) ("The very fact that the defendants chose to join the plaintiffs in selecting this remedy would seem to mean--and must be taken to mean--that they understood it to be precisely tailored to the needs of the occasion, that it is narrowly drawn and least intrusive-in fact not intrusive at all."); Benjamin v. Fraser , 156 F. Supp. 2d 333 , 344 (S.D.N.Y. 2001) (Baer, J.) (reasoning that an agreement between the parties that is incorporated into an order "constitutes strong evidence" of compliance with the need-narrowness-intrusiveness requirement); cf. Cason , 231 F.3d at 785 n.8 ("Of course, we do not mean to suggest that the district court must ... enter particularized findings concerning any facts or factors about which there is no dispute."). Indeed, common sense dictates that, as a general proposition, a penal institution would release to a court or other outside entity only as much of its discretion and authority as it believes the law and facts require.
Second, despite agreeing to them, ADOC has consistently failed to comply with the provisions of the interim agreement. And more generally, the ongoing inadequacies in ADOC's suicide-prevention efforts show that the agreement remains urgent and necessary.
Third, in their briefing, the defendants make no specific objections to the interim agreement's requirements. Their arguments against them relate to only notice and mootness. As explained above, those arguments are meritless.
1. Licensed Mental-Health Professionals at Treatment Hubs
In the liability opinion, the court found that "[t]he quality of psychotherapy ... suffers due to use of unsupervised, unlicensed counselors, referred to as 'mental health professionals' [ (MHPs) ]." Braggs , 257 F. Supp. 3d at 1211 . The lack of supervision for unlicensed MHPs was found to be "a significant, system-wide problem affecting the delivery of mental-health care within ADOC." Id.
The interim agreement addresses this problem. The relevant provision requires that each "Major Facility" 20 have at least one full-time licensed MHP, 21 and that the *1254 treatment hubs--Bullock, Donaldson, and Tutwiler--have at least two full-time licensed MHPs. See Interim Agreement (doc. no. 1106-1) at 1. The agreement further requires that two licensed MHPs be on site for at least eight hours per day every business day at each treatment hub, and that at least one MHP be at each treatment hub on the weekends and holidays. See id.
The court finds that ordering immediate and permanent implementation of this provision constitutes relief that is narrowly drawn, extends no further than necessary to correct the defendants' constitutional violation, and is the least intrusive means necessary to correct the violation. See 18 U.S.C. § 3626 (a)(1)(A).
In addition to the original liability findings, evidence presented at the suicide-prevention trial further demonstrates that the provision is necessary. Dr. Burns testified that the required numbers of licensed MHPs in major facilities and treatment hubs are the "minimum numbers of people" that must be available "to provide an adequate suicide prevention program." Burns Apr. 8, 2019, R.D. Trial Tr. at 133. In her view, there is no less intrusive requirement that would still be effective. See id. Crucially, MHPs must have the required licensing to be able to work independently, without supervision. Id. at 129-30 . According to Dr. Burns, they must be available every day, including weekends, to check on inmates, including those who have been placed on suicide watch. See id. at 130 . Adequate licensed MHP staffing is also needed to complete the suicide risk assessments and follow-up appointments required elsewhere in this opinion. Finally, the defendants agreed to include this requirement in the interim agreement, which is strong evidence that it satisfies the need-narrowness-intrusiveness criteria. See, e.g. , Fraser , 156 F. Supp. 2d at 344 .
2. Who May Present a Prisoner for Suicide Watch
The liability opinion found that ADOC fails to "provide suicide-prevention services and crisis care to many prisoners who need it," in part due to "inadequate identification of those who are at heightened risk of suicide." Braggs , 257 F. Supp. 3d at 1221 . The systemwide understaffing of both mental-health care providers and correctional officers contributes to this problem. See id. at 1193 .
Against this backdrop, the interim agreement provides that all employees of ADOC and its mental-health and medical-care contractor (currently Wexford) have the authority to "present a person to mental health or medical staff for assessment for suicide watch." Interim Agreement (doc. no. 1106-1) at 1. Whoever places the inmate on watch must notify appropriate Wexford staff. 22 See id. If the inmate is identified when no Wexford staff is on-site, the appropriate Wexford on-call staff must be notified. See id.
The court finds that ordering immediate and permanent implementation of this provision constitutes relief that satisfies the PLRA's need-narrowness-intrusiveness requirement. See 18 U.S.C. § 3626 (a)(1)(A).
Dr. Burns testified that this provision is necessary, given that an adequate suicide-prevention *1255 program must have "a low threshold" for putting someone on suicide watch until their risk is fully assessed. Burns Apr. 8, 2019, R.D. Trial Tr. at 134. To have the required "low threshold" for suicide-watch placement, both correctional and mental-health staff must have the authority to initiate the referral process by presenting them to mental-health or medical staff for assessment.
Furthermore, correctional and mental-health understaffing remains a serious problem. As of December 2018, ADOC reported that 62 % of correctional officer positions were vacant, see March 2019 Quarterly Staffing Report (doc no. 2386-1) at 3, and as of September 2018, 23.6 % of the mental-health positions were vacant, see December 2018 Quarterly Staffing Report (doc. no. 2378-1) at 9. The more understaffed ADOC is, the fewer the eyes on prisoners, and the more necessary it is that the broadest possible scope of employees at the facilities be authorized to identify inmates for a potential placement on suicide watch.
The need to clearly authorize correctional staff to refer inmates for suicide watch is also demonstrated by recent instances in which correctional officers should have referred inmates to mental-health, but did not. For example, as detailed above, less than two weeks after cutting his wrist, being placed on suicide watch, and then returning to segregation, Kendall Chatter loudly yelled and banged on his segregation cell for a sustained period. In response, the correctional shift supervisor instructed his subordinate to let him keep banging and yelling until he tired himself out. Shortly after Chatter started making the noise--according to one record, less than an hour later--he was found hanging.
Finally, the defendants agreed to include this requirement in the interim agreement, which is strong evidence that it satisfies the need-narrowness-intrusiveness standard. See, e.g. , Fraser , 156 F. Supp. 2d at 344 .
3. Constant Watch Until Initial Assessment for Suicide Watch
As found in the liability opinion, ADOC's monitoring of suicidal prisoners is "woefully inadequate." Braggs , 257 F. Supp. 3d at 1229 . Unsafe features of crisis cells--such as physical structures that provide opportunities to commit suicide, obstacles to visibility into a cell, and access to dangerous items such as sharp implements--"heighten the importance of monitoring prisoners for signs of decompensation or suicide attempts." Id.
The interim agreement provides that, "[u]pon being presented to mental health or medical staff for assessment for suicide watch, each person will be maintained under 'constant watch' at least until they have been evaluated" using a suicide risk assessment. Interim Agreement (doc. no. 1106-1) at 1. "Constant watch" is a procedure defined in the agreement as ensuring one-on-one visual contact at all times, except to the extent the physical design of the cell gives the observer a continuous unobstructed view of up to two people on watch. See id.
The court finds that ordering immediate and permanent implementation of this provision constitutes relief that satisfies the PLRA's need-narrowness-intrusiveness requirement. See 18 U.S.C. § 3626 (a)(1)(A).
Dr. Burns testified that an adequate suicide-prevention program requires that once a prisoner is identified to be assessed for suicide watch, he must remain on constant watch until the assessment is completed. See Burns Apr. 8, 2019, R.D. Trial Tr. at 133-34. As she explained, a less intrusive requirement would be insufficient, because if a person is at risk, he must be subject to continuous watch until someone can "truly assess" the level of *1256 risk. Id. at 134 . Along similar lines, Dr. Raymond Patterson, the defendants' correctional mental-health care expert, opined at the liability trial that suicidal prisoners should be under direct, constant watch while in suicide-watch cells. See Braggs , 257 F. Supp. 3d at 1228 . He testified that camera observation by an officer at a control station "may not be sufficient, because by the time that officer notices a suicide attempt, it might be too late," and that, in any case, "the officer likely has other responsibilities that would preclude careful monitoring of any single cell." Id.
Furthermore, the defendants agreed to include this provision in the interim agreement, which also shows that it satisfies the need-narrowness-intrusiveness standard. See, e.g. , Fraser , 156 F. Supp. 2d at 344 . At the same time, however, ADOC has repeatedly failed to comply with the spirit of the provision, demonstrating the need to order its immediate implementation. As detailed above, in several of the recent cases of suicides, ADOC responded to the men's expressed suicidality by placing them on MHO instead of constant watch. See also Pls. Ex. 2710 at ADOC0475738 (Crook's letter to Wexford identifying the systemic "[f]ailure to place an inmate on acute suicide watch with constant observation (rather than MHO) when risk factors for potential suicidality are present until a psychologist or psychiatrist is consulted").
4. Suicide Risk Assessment After Initial Placement on Suicide Watch
Previously this court found that ADOC's "failure to perform proper suicide risk assessments to identify prisoners with a heightened risk of suicidal behavior places seriously mentally ill prisoners at an 'obvious,' substantial risk of serious harm." Braggs , 257 F. Supp. 3d at 1221 .
The interim agreement addresses inadequate suicide risk assessments. The relevant provision requires that once an inmate is placed on constant, he must receive a suicide risk assessment to determine whether he is "acutely" or "nonacutely" suicidal. Interim Agreement (doc. no. 1106-1) at 1-2. Specifically, the suicide risk assessment must (1) be conducted in an out-of-cell, confidential setting, either by (2) licensed psychiatrists or psychologists (with specific provisions applying if via telepsychiatry), 23 or (3) by Certified Registered Nurse Practitioners (CRNPs) or licensed MHPs if they are in person and afterwards confirmed with a psychiatrist or psychologist, and (4) only if the CRNPs and licensed MHPs have first completed approved training on suicide prevention, assessing suicidality, and suicide watch procedures. See id. at 1-2. 24
The court finds that ordering immediate and permanent implementation of this provision *1257 constitutes relief that satisfies the PLRA's need-narrowness-intrusiveness requirement. See 18 U.S.C. § 3626 (a)(1)(A).
As explained in the liability opinion, adequate mental-health care requires face-to-face risk assessments by appropriately qualified practitioners:
"[T]he administration of a suicide risk-assessment and management tool by a qualified provider is widely recognized to be an essential part of mental-health care: it should be used as a part of the intake screening process and whenever a prisoner threatens or attempts to harm himself or actually does so.... As defense expert Dr. Patterson explained, the suicide risk-assessment tool must be completed in a face-to-face encounter by a high-level provider or a mid-level provider with high-level supervision, because the tool comes with clinical guidelines and requires clinical judgment."
Braggs , 257 F. Supp. 3d at 1221 .
Consistent with this finding in the liability opinion, Dr. Burns more recently testified that the provision in the interim agreement is necessary for an adequate suicide-prevention program, because it ensures standardized, accurate assessments, and that the evaluators are properly trained--as well as licensed and approved by law--to conduct independent assessments. See Burns Apr. 8, 2019, R.D. Trial Tr. at 135. Furthermore, both Drs. Burns and Perrien testified that it is important to have these kinds of mental-health contacts in an out-of-cell, confidential setting, see Burns and Perrien Apr. 9, 2019, R.D. Trial Tr. at 11, 199-201, and both recommend that ADOC be required to immediately adhere to confidentiality requirements, see Immediate Relief Recommendations (doc. no. 2416-4) at 4.
Director of Mental Health Services Crook testified that she agrees with the provision's qualification requirements, as well as its requirement that the MHPs and CRNPs receive training prior to completing the assessments. See Crook Apr. 2, 2019, Trial Tr. (doc. no. 2488) at 17. Indeed, as with the other provisions in the interim agreement, the defendants agreed to include this provision in the interim agreement, which also supports the finding that it satisfies the need-narrowness-intrusiveness standard. See, e.g. , Fraser , 156 F. Supp. 2d at 344 .
Critically, however, ADOC has repeatedly failed to comply with the provision. Crook specifically identified the systemic "[f]ailure to complete the Suicide Risk Assessment (SRA) by a Qualified Mental Health Professional (QMHP) when an inmate is placed in a crisis cell." Pls. Ex. 2710 at ADOC0475738. As detailed above, in several of the recent 15 suicides, ADOC either inadequately conducted risk assessments or altogether failed to do them. Another compliance problem is that, as Drs. Burns and Perrien found, mental-health staff began providing suicide risk assessments prior to receiving the requisite training. See Joint Expert Report and Recommendations (doc. no. 2416-1) at 10. Indeed, Dr. Burns was never asked to review and approve the training, as required by the interim agreement. See Burns Apr. 8, 2019, R.D. Trial Tr. at 114.
5. Applying Definitions of "Acutely Suicidal" and "Nonacutely Suicidal "
The interim agreement provides that, when conducting the suicide risk assessment to determine if an inmate is "acutely suicidal" or "nonacutely suicidal," mental-health staff must apply those terms as they are defined by the National Commission on Correctional Health Care standard MH-G-04. 25
*1258 The court finds that ordering immediate and permanent implementation of this provision constitutes relief that satisfies the PLRA's need-narrowness-intrusiveness requirement. See 18 U.S.C. § 3626 (a)(1)(A).
The defendants agreed to include this provision in the interim agreement, which shows that it satisfies the need-narrowness-intrusiveness standard. See, e.g. , Fraser , 156 F. Supp. 2d at 344 . 26 Indeed, ADOC's contract with Wexford requires it to comply with NCCHC standards--providing further evidence that the provision is not intrusive. See Pls. Ex. 1302 at 3. Finally, the court heard overwhelming evidence that ADOC has placed prisoners on levels of watch and observation that are incommensurate to their risk of self-harm, and that these erroneous placements affect the level of treatment and monitoring that the inmates receive. Applying these definitions going forward is necessary to ensure consistency and accuracy in identifying suicide risk, so that inmates receive appropriate treatment and monitoring.
6. Constant Watch for Acutely Suicidal Prisoners
Previously this court found that, "[f]or the most acutely suicidal, constant--rather than staggered-interval--watch is necessary." Braggs , 257 F. Supp. 3d. at 1229 . As the court explained, "correctional systems must have a constant-watch procedure for individuals whose risk of suicide is the highest, due to their engagement in self-injurious behavior or threat of suicide with specific plans: if a prisoner is waiting for an opportunity to kill himself, it is too dangerous to walk away, and he must be constantly observed. For this reason, the NCCHC standards classify constant-watch procedures as an 'essential' standard." Id.
The interim agreement says that "any person who is determined to be acutely suicidal shall be monitored through a constant watch procedure." Interim Agreement (doc. no. 1106-1) at 2. 27 The court finds that ordering immediate and permanent implementation of this provision constitutes relief that satisfies the PLRA's need-narrowness-intrusiveness requirement. See 18 U.S.C. § 3626 (a)(1)(A).
To start, the court already concluded that constant watch is "necessary" for inmates who are at the highest risk of suicide. Braggs , 257 F. Supp. 3d. at 1229 . "Acutely suicidal"--as opposed to "nonacutely suicidal"--inmates are the ones who have the highest risk. The court also makes the PLRA findings here largely for the same reasons that the court identified above in finding that requiring constant watch until a person receives a suicide risk assessment satisfies the PLRA. If constant watch is necessary to protect a potentially suicidal person whose risk level is not yet determined, a fortiori constant watch is necessary when they have already been determined to have the highest possible risk of suicide.
The defendants and both parties' experts have widely recognized the necessity of the requirement, given that acutely suicidal *1259 individuals are at "imminent risk of self-harm." Perrien Apr. 9, 2019, R.D. Trial Tr. at 82; see Burns Apr. 8, 2019, R.D. Trial Tr. at 136 (testifying that constant watch is necessary for acutely suicidal inmates); Kern Mar. 28, 2019, Trial Tr. (doc. no. 2482) at 116 (testifying that an acutely suicidal inmate must be placed on constant watch); Naglich Dec. 20, 2016, Trial Tr. at 232-34 (acknowledging during the liability trial that ADOC's failure to provide constant watch to acutely suicidal inmates was a problem that needed to be addressed immediately--"th[at] afternoon" even--because their lives were at risk). Dr. Burns testified that these same procedures "have been in place in multiple systems for decades." Burns Apr. 8, 2019, R.D. Trial Tr. at 137. And Dr. Perrien testified that it was her understanding that certain components of the interim agreement, including acute watch, "would forever remain in place ... [b]ecause those just are a function of any suicide prevention program." Perrien Apr. 9, 2019, R.D. Trial Tr. at 58-59.
Furthermore, the defendants agreed to include this provision in the interim agreement, which also shows that it satisfies the need-narrowness-intrusiveness standard. See, e.g. , Fraser , 156 F. Supp. 2d at 344 . Nevertheless, ADOC still has not revised its suicide-prevention policies to require constant watch for acutely suicidal prisoners. See Jt. Ex. 132 (ADOC Admin. Reg. 629); Jt. Ex. 133 (ADOC Admin. Reg. 630). Worse yet, ADOC has not adequately complied with the requirement, demonstrating the need to order immediate implementation. For example, while "Person Incarcerated at Tutwiler" 28 was on constant watch, she was seen placing an object in her mouth, and shortly thereafter cutting herself--without any reported intervention. See Pls. Ex. 2323 (medical records of Person Incarcerated at Tutwiler). In none of the facilities visited by Drs. Burns and Perrien "were the 'watchers' positioned appropriately to permit full visibility into the safe cells or constant visibility of the inmates being observed." Joint Expert Report and Recommendations (doc. no. 2416-1) at 26.
7. Close Watch for Nonacutely Suicidal Prisoners
According to "the standard of care for mental-health care in prisons, suicide-watch checks should take place at staggered, or random, intervals of approximately every 15 minutes, rather than exactly every 15 minutes." Braggs , 257 F. Supp. 3d at 1229 .
Consistent with this standard of care, the interim agreement requires that any inmate determined to be nonacutely suicidal must be monitored through a "close watch" procedure that "ensures monitoring by ADOC staff at staggered intervals not to exceed every 15 minutes." Interim Agreement (doc. no. 1106-1) at 2.
The court finds that ordering immediate and permanent implementation of this provision constitutes relief that satisfies the PLRA's need-narrowness-intrusiveness requirement. See 18 U.S.C. § 3626 (a)(1)(A).
First, as the court explained in the liability opinion, "[s]taggered intervals prevent prisoners from timing their suicide attempts, because otherwise they can predict exactly when checks will occur. Such monitoring procedures are all the more crucial when suicidal inmates are housed in cells that have little visibility: as plaintiffs' expert Vail bluntly stated, without regular checks, '[Y]ou have no idea if they're alive or dead.' " Braggs , 257 F. Supp. 3d at 1229 .
*1260 The "unsafe features" of ADOC's suicide watch cells "heighten the importance" of the close watch procedure. Id.
Second, Dr. Burns testified that the close-watch procedures are a necessary component of an adequate suicide-prevention program. See Burns Apr. 8, 2019, R.D. Trial Tr. at 136. She said that same "close watch procedures have been in place in multiple systems for decades." Id. at 137.
Third, the defendants agreed to include the close watch provision in the interim agreement, which also shows that it satisfies the need-narrowness-intrusiveness standard. See, e.g. , Fraser , 156 F. Supp. 2d at 344 .
Fourth, despite agreeing to the requirement, ADOC repeatedly failed to comply with it. Matthew Holmes was placed in MHO instead of suicide watch even though, as Mental Health Services Director Crook admitted, he met the NCCHC's definition of nonacutely suicidal. Less than a week later, he killed himself. Similarly, Timothy Chumney was placed in MHO instead of suicide watch, despite being classified as having a moderate risk of suicide. Like Holmes, he killed himself less than a week later.
8. Suicide Watch Observation Logs
The interim agreement requires that both constant and close watch be "contemporaneously documented at staggered intervals not to exceed 15 minutes on a record maintained on each individual cell door. Upon discharge from suicide watch, these records will be maintained in a facility-based suicide watch log and in the individual prisoner's medical record." Interim Agreement (doc. no. 1106-1) at 2.
The court finds that ordering immediate and permanent implementation of this provision constitutes relief that satisfies the PLRA's need-narrowness-intrusiveness requirement. See 18 U.S.C. § 3626 (a)(1)(A). This provision is needed to ensure that ADOC properly implements the constant and close watch procedures, which are essential protections for suicidal inmates. In short, without the required documentation, there is no way to know whether ADOC is carrying out the mandated observation. If the logs are pre-filled--as they have been repeatedly during this litigation--it "makes it impossible to ensure that staggered checks are actually happening." Braggs , 257 F. Supp. 3d at 1229 . Such a situation would be untenable. ADOC cannot be left to its own devices to comply with court orders. As the court monitoring section below demonstrates, ADOC officials and staff must be held accountable--both internally and to the court--for carrying out remedial orders, especially the suicide watch requirements, which can have life or death consequences.
That the defendants agreed to include this provision in the interim agreement, yet have had problems complying with it, also demonstrates the need for ordering its immediate implementation. Shortly after the parties reached the agreement, the court found noncompliance:
"Associate Commissioner Naglich admitted that staff are not permitted to use monitoring logs with pre-printed times, but that some continue to use them. She also testified that officers and staff are not permitted to handwrite times and signatures in advance of, or in lieu of, their actual checks. However, during the post-trial prison tours, the court came across multiple logs where times at 15-or 30-minute intervals had been pre-filled, even though the parties had agreed during the trial to correct this practice, and the court had ordered compliance with the agreement several weeks before the tours. This evidence of non-compliance greatly troubled the court, as it showed that policy changes are not being implemented on the ground even when a court order is involved."
*1261 Braggs , 257 F. Supp. 3d at 1229 . Although the experts recently reported "significant progress" in this area, see Joint Expert Report and Recommendations (doc. no. 2416-1) at 26, 29 noncompliance has continued since the liability opinion, see, e.g. , Burns Dec. 6, 2018, Trial Tr. (doc. no. 2254) at 144, 147, 165-67 (testifying about unstaggered logs and precalculated times); Pls. Ex. 1823 at SPA_4177 (showing unstaggered logs on acute suicide watch).
9. Administrative Regulations Regarding Suicide Prevention
The interim agreement required ADOC to revise Administrative Regulation 630--which mandated 15-minute intervals for monitoring on suicide watch--so that it reflects the constant and close watch procedures set forth in the agreement. See Interim Agreement (doc. no. 1106-1) at 2. Two years later, the defendants have still not incorporated this requirement into Administrative Regulation 630, which was last updated in 2005. See Jt. Ex. 133 (ADOC Admin. Reg. 630).
The court finds that ordering immediate and permanent implementation of this provision constitutes relief that satisfies the PLRA's need-narrowness-intrusiveness requirement. See 18 U.S.C. § 3626 (a)(1)(A).
As Dr. Burns testified, "the administrative regulation is the department's policy for all intents and purposes ... and needs to contain the information that's also contained in this [interim agreement] with the different levels of watch." Burns Dec. 6, 2018, Trial Tr. (doc. no. 2254) at 128. Put simply, ADOC is more likely to comply with the court's orders if they are incorporated into its own policies. Furthermore, that the defendants agreed to include this provision in the interim agreement shows that it satisfies the need-narrowness-intrusiveness standard. See, e.g. , Fraser , 156 F. Supp. 2d at 344 .
10. Monthly Evaluations of Suicide Risk Assessments
The interim agreement requires that all suicide risk assessments be reviewed monthly by certain clinical staff at ADOC's Office of Health Services (OHS)--which is responsible for overseeing the provision of medical and mental-health care to prisoners--and Wexford. Based on this review, the clinical staff "will issue immediate corrective actions and training if necessary." Interim Agreement (doc. no. 1106-1) at 2.
The court finds that ordering immediate and permanent implementation of this provision constitutes relief that satisfies the PLRA's need-narrowness-intrusiveness requirement. See 18 U.S.C. § 3626 (a)(1)(A).
Requiring senior clinical staff to review the quality of suicide risk assessments is necessary given that, as found in the liability opinion, ADOC's "failure to perform proper suicide risk assessments ... places seriously mentally ill prisoners at an 'obvious,' substantial risk of serious harm." Braggs , 257 F. Supp. 3d. at 1221 . More recently, Dr. Kern confirmed that clinicians should exercise oversight of suicide risk assessments to determine that clinical judgment is appropriate. See Kern Mar. 28, 2019, Trial Tr. (doc. no. 2482) at 118.
The defendants agreed to include this provision in the interim agreement, showing that it satisfies the need-narrowness-intrusiveness standard. See, e.g. , Fraser , 156 F. Supp. 2d at 344 . But Crook admitted that OHS staff did not begin the required monthly reviews of the suicide risk assessments until March 2019, more than *1262 two years after the defendants agreed to do them. See Crook Apr. 1, 2019, Trial Tr. (doc. no. 2485) at 43-44.
Finally, the need for review of the assessments is underscored by ADOC's ongoing failure to properly conduct them. See, e.g. , Burns Dec. 6, 2018, Trial Tr. (doc. no. 2254) at 134-35, 137-43, 146-47. For example, Paul Ford's suicide risk assessment stated that he had no recent "suicidal/self-injurious" behavior or ideation, even though he had cut his wrist just eight days earlier. See Pls. Ex. 2309 at SPA_9674. Shortly after, he was released back into segregation, and killed himself less than a month later.
11. Discharge from Suicide Watch
In the liability opinion, the court concluded that "[p]risoners are routinely released from suicide watch improperly." Braggs , 257 F. Supp. 3d. at 1230 . As the defendants' and plaintiffs' experts explained at the time, "suicidal prisoners should be released only with the approval of a psychiatric provider (psychiatrist or nurse practitioner) who has made a face-to-face assessment that their condition was sufficiently stabilized to warrant it." Id. But that was not occurring:
"In 2016, [the then-mental-health care vendor] reported to ADOC that it was discharging patients from suicide watch without a face-to-face assessment; the decisions were based instead on whatever information lower-level mental-health staff communicated over the phone to on-call doctors and nurse practitioners.... Associate Commissioner Naglich admitted that this practice of authorizing suicide watch release without a face-to-face evaluation was not specific to any particular facilities, but that it reflected a general shortage of psychiatrists; she further agreed that it put the prisoners at risk of premature release. Evidence also showed that prisoners have, on occasion, been released from suicide watch by correctional staff without any mental health assessment at all; this is even more unacceptable."
Id. at 1230-31 .
The interim agreement provides the following requirements for discharging a prisoner from suicide watch (also referred to as "discharge protocols"):
"10. A person may be discharged from suicide watch following an out of cell, confidential evaluation according to the following terms.
a. Licensed psychiatrists or licensed psychologists may conduct these evaluations either in person or by telepsychiatry. In the event that they are conducted by telepsychiatry, the person being evaluated will be in a room with a mental health professional (licensed or otherwise), psychological associate (licensed or otherwise), or CRNP.
b. CRNPs may conduct these evaluations but only if they are conducted in person. Upon conducting any such evaluation, a CRNP must confirm their assessment with a psychiatrist or psychologist either in person, by telepsychiatry, or over the phone. The psychiatrist or psychologist must be provided with and review the risk assessment and the notes of the mental health evaluations and counseling that have been conducted in the past 14 days.
c. Once the licensed MHPs are in place at each facility, they may conduct these evaluations but only if they are conducted in person and confirmed with a psychiatrist or psychologist as described in [10].b. above.
d. A person may not be discharged from suicide watch via telepsychiatry until the person conducting the evaluation has sought input from the MHP or counselor who has been primarily *1263 responsible for providing mental health services to the person on suicide watch, except in exceptional circumstances, which shall be documented.
e. Prior to conducting any such evaluations, licensed MHPs and CRNPs must complete a training on suicide prevention, assessing suicidality, and procedures of suicide watch. This training must be approved by Associate Commissioner Ruth Naglich, Dr. David Tytell, Dr. Robert Hunter, Dr. Charles Woodley (or any subsequent replacements), and the agreed-upon monitor or Plaintiffs' experts if the agreed-upon monitor has not yet been retained.
f. Each patient placed on constant watch will be reduced to a close watch prior to release from suicide watch."
Interim Agreement (doc. no. 1106-1) at 2-3.
The court will adopt these requirements, with the slight modification that Drs. Burns and Perrien must approve the training for licensed MHPs and CRNPs. 30 The court finds that ordering immediate and permanent implementation of these requirements constitutes relief that satisfies the PLRA's need-narrowness-intrusiveness requirement. See 18 U.S.C. § 3626 (a)(1)(A).
First, the findings and expert testimony from the liability trial cited above concerning the failure to use proper discharge practices show that the ordered protocols are necessary. Dr. Burns also recently testified that the protocols are necessary for an adequate suicide-prevention program, explaining that suicide risk must be assessed by "someone who's independently licensed to exercise their judgment using a standardized assessment to make decisions about the level of risk." Burns Apr. 8, 2019, R.D. Trial Tr. at 137.
Second, although the defendants' agreed to the protocols in the interim agreement, which in and of itself is strong evidence of PLRA compliance, see , e.g. , Fraser , 156 F. Supp. 2d at 344 , they have repeatedly failed to comply with them since the liability trial. Indeed, Mental Health Services Director Crook identified the systemic "[f]ailure to document consultation with a psychiatrist or psychologist prior to discharging an inmate from crisis placement." Pls. Ex. 2710 at ADOC0475738.
Third, ADOC's acknowledgement that the majority of suicides in its system have involved men released from suicide watch to segregation is compelling evidence of the urgent need to adopt these minimally adequate discharge protocols. See Pls. Ex. 2706.
12. Suicide Watch Follow-Up Appointments
In the liability opinion, the court found that inmates "receive inadequate follow-up care after their release from suicide watch," contributing to a "substantial risk of recurring self-injurious behavior and suicide." Braggs , 257 F. Supp. 3d at 1230 .
To address this deficiency, the interim agreement requires that, upon release from suicide watch, each inmate will have at least three confidential and out-of-cell follow-up appointments. See Interim Agreement (doc. no. 1106-1) at 3-4. The interim agreement provides that "follow-up examinations do not take the place of otherwise scheduled mental-health appointments, though they may occur in connection with or contiguous with such appointments." Id. at 3. The interim agreement also allowed follow-up appointments *1264 to be conducted either by licensed psychiatrists or psychologists, or alternatively by CRNPs or licensed MHPs. See id. at 4. If CRNPs or MHPs conduct the evaluations, they must do so in person and confirm their assessment with a psychiatrist or psychologist. Prior to conducting any such follow-up examinations, licensed MHPs and CRNPs must complete an approved training on suicide prevention, assessing suicidality, and procedures of suicide watch. See id.
The court finds that ordering immediate and permanent implementation of these requirements--as slightly modified by the exp

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Source: Frix Law Library, https://www.frixlaw.com/law-library/cases/7254134. Public record. Not legal advice.