Disability Rights Maryland is the state’s designated authority under federal law for conducting investigations into allegations of abuse and negligence for people with disabilities. The group, along with Munib Lohrasbi of the Open Society Institute of Baltimore, launched a review after Butler’s death in segregation.
The report’s findings were based on interviews with women in the segregation unit at the time of Butler’s death, video security footage of the unit, and a review of the prison’s records and log sheets. Investigators also made site visits, reviewed information provided by the warden, interviewed health-care contractors, inmates and people who provide advocacy and programming for the prison.
The report found that “the restrictive conditions, applied to individuals with serious disabilities, violates the 8th Amendment of the United States Constitution, which prohibits cruel and unusual punishment, including deliberate indifference to the health care needs of incarcerated individuals.” It found the prison also violated the Maryland Constitution and the Americans With Disabilities Act.
“The harm from prison segregation practices is pointedly evidenced by the death of Ms. Butler,” the report noted.
Michael Zeigler, the deputy secretary of operations for the Maryland Department of Public Safety and Correctional Services, said in an email Friday that the department, along with Warden Margaret Chippendale, “have been nationally recognized for treating inmates with dignity.”
“With her 40 years of correctional experience, Warden Chippendale is known throughout the state for implementing innovative prison programs, ranging from providing healthy inmate meals to devising a system to divert more inmates from restrictive housing,” Zeigler said in the statement. “We take our mission to protect the public, our staff and the inmates in our custody very seriously and remain confident that the warden and her staff are doing everything in their power to keep the inmates at their institution safe.”
When Butler was admitted to the Maryland Correctional Institute for Women in 2015, her extensive mental health history was documented during a psychiatric evaluation, according to the Disability Rights Maryland report. She had been receiving mental health services in the community since 2008 for depressive, bipolar and post-traumatic stress disorders, and she had a history of multiple self-injury and suicide attempts before her incarceration, all of which was documented in her prison medical records, the report noted.
Butler was prescribed psychiatric medications to address her anxiety and depression but never received regular counseling, according to the report. Butler’s depression medications were also changed to address her increased depression symptoms a week before her death.
On Nov. 10, 2017, Butler was sent to segregation — individual cells most commonly used after an person has been accused of committing an infraction — after she threw coffee on another inmate during a dispute. She was not screened or evaluated for mental health concerns before being placed in segregation, the report said.
Multiple women told investigators Butler was distraught over her argument with her friend and worried her disciplinary charges would affect her chance for parole, for which she would have been eligible in April 2018, the report said. She repeatedly asked to speak with her father or for mental health help over a period of two days, according to the report. She was not allowed out of her cell unless it was to shower, the report said.
According to the report, prison policy requires the segregation unit staff to supervise and monitor inmates’ behavior and to make security rounds every 30 minutes. Butler was last accounted for during the morning count at 7:30 a.m., according to the report, and she was not found until the lunch trays were delivered around 10:15 a.m.
She was declared dead at 11 a.m., but her body lay on the floor in the middle of the segregation unit for hours until the medical examiner arrived, the report said.
Baltimore Sun reporter Justin Fenton contributed to this article.