Zach Wendling
LINCOLN — A state prison watchdog is again urging the Nebraska Department of Correctional Services to stop double-bunking inmates in restrictive housing, at least by the time the new state prison is opened.
In a 38-page report released Thursday, the Office of Inspector General of Corrections outlined findings into the 2022 death of an inmate, “John Doe,” who died two days after another inmate, “John Smith,” was moved into his cell. About three months earlier, staff recommended Doe’s removal from long-term restrictive housing, and he was scheduled for a review of his housing.
That review never came, however, as he died three days before it was scheduled.
The inspector general has raised similar concerns in the past about double-bunking, notably after the 2017 killing of a 22-year-old double-bunked inmate at Tecumseh State Correctional Institution, when the office recommended suspending “double-bunking” in restrictive housing until after further examination. The department rejected that recommendation.
The inspector general, in at least two more reports, later encouraged the state to completely end the practice. It continues only at the Nebraska State Penitentiary in Lincoln.
“Restrictive housing is a volatile setting, even for a correctional facility, and staff cannot be expected to determine which cellmates are safe and which ones are not in these circumstances,” the report states.
The Office of Inspector General of Corrections is a legislatively created office established in 2015 to increase accountability and oversight of the Corrections Department. It investigates all deaths in department facilities.
The death of ‘John Doe’
In this case, Doe was placed in the restrictive housing unit about five months before his death, after staff found a 5-inch homemade weapon in his pocket, though Doe made progress in completing all nine “Courage to Change” booklets and three different nonclinical programming books available on the unit.
Doe wrote in an “inmate accountability statement” the week of his death that he had dealt with depression, family problems and “other things I have no control over,” but that if he returned to the yard, he could take better control of his life, get more programming and finish school.
“I really do want to make a change & I am not saying that just to get out the hole,” he wrote. “I really do want to change my life around & educate myself more & become a better person for myself & my son on the streets.”
Smith, Doe’s later cellmate, was moved into a single cell after talking with a mental health practitioner three days before Doe’s death, and when Smith needed to be moved back into a double-bunked setting, he specifically asked to live with Doe.
Staff completed the required documentation and checked with Doe to ensure he was comfortable with the change. After the two were double-bunked, a case manager spoke with both men separately, and neither expressed concerns at the time, according to the report.
The next day, staff found Doe unresponsive on his cell floor shortly after 4 p.m. After about a 25-minute emergency response, Doe was declared dead.
An autopsy two days after said Doe died of “asphyxia with a ligature,” or a lack of oxygen.
Corrections staff notified the Office of Inspector General within a few hours of the incident with an email that contained his name and the subject line “NSP suicide.”
Inspector General Doug Koebernick said in an email Friday that whether Doe died by suicide or homicide is not known. The report indicates that some details about the scene were omitted because of an ongoing criminal case related to Doe’s death.
The report doesn’t identify Doe or Smith by their real names, but the case is similar to the October 2022 death of 26-year-old Philip Garcia. A Lancaster County grand jury indicted Garcia’s cellmate, Tyler Stanford, 38, on a charge of first-degree murder in May 2024.
Policy of double-bunking inmates
The inspector general’s report indicates that there are some benefits for double-bunking in these settings, such as increasing capacity in overcrowded systems (like Nebraska’s), less isolation, the ability to share items and the possible reduction in self-injury, or suicide.
However, there are also disadvantages, including lack of physical space, lack of privacy, difficulty searching cells or identifying the owner of any found contraband, a sense of heightened risk to staff when they need to open cells in an incident, possible sexual victimization without witnesses and possible assault or homicide.
The inspector general could not find any comprehensive examination of whether the combined risk of death, either by suicide or homicide, is greater in single- or double-bunked restrictive housing cells.
“Some research has found that people are more likely to die by suicide in single-cell disciplinary housing; however, the recommended solution was more attention by staff, not double-bunking,” the report continues.
In the past four years, three people have killed themselves all in single-bunked confinement in Nebraska prison facilities. Meanwhile, in the same time frame, there have been three suspected homicides, and in each instance, the person’s cellmate was the suspected killer.
It’s unclear whether the Doe case is included in the cases counted for those years.
One staff member told the investigators that double-bunking had become the “expectation” and was treated as “business as usual” among higher-ups.
The report states that unit staff were told a month before Doe’s death that double-bunking decisions were in line with department policy and that they should pair up as many people as possible “to free up as many cells as possible” in the restrictive housing unit.
The inspector general said department policy allows people to be double-bunked in restrictive housing “so long as the cell assignment provides each cellmate with reasonable safety from assault.”
The report says staff followed the policy.
“It has been an agency goal to reduce the behavior that results in restrictive housing,” Dayne Urbanovsky, a department spokesperson, said in a Friday email, “and through multiple improvements made by NDCS over the last two years, use of double-bunking in restrictive housing at NSP has been largely reduced.”
Policy recommendations
Currently, the Corrections Department is out of compliance with the American Correctional Association, through which the department is accredited, for double-bunking any inmates in restrictive housing because the cells are too small.
The report states that the Corrections Department’s “plan of action” is new construction. The new replacement facility isn’t expected to be completed until at least 2028.
The report offers multiple recommendations if double-bunking continues:
- Require warden-level approval or higher for double-bunking placements in restrictive housing, which should be cellmate-specific and granted beforehand, or within 24 hours in emergencies.
- Clarify whether double-bunking is allowed in longer-term restrictive housing.
- Prohibit double-bunking co-defendants while in restrictive housing.
- Review the violence risk score used for cell assignments and determine whether they can be updated periodically, or removed altogether if not.
- Prohibit placing cellmates with people in restrictive housing who are considered to be a high risk of violence to other incarcerated individuals.
Investigation roadblock
The Office of Inspector General completed its initial investigative work into Doe’s death almost immediately and suspended its investigation pending further law enforcement investigation.
However, in August 2023, an advisory opinion from Nebraska Attorney General Mike Hilgers questioned the constitutionality of the inspectors general of corrections and child welfare. That led the Corrections Department to suspend the officials’ access to facilities, records and staff.
No state official filed a lawsuit against the laws, and no court blocked the laws.
Access was partially restored to the Office of Inspectors General in February through a memorandum of understanding between the Legislature and the Executive Branch. The Legislature created a committee to fully examine its oversight authority, which the office of State Sen. John Arch of La Vista, the speaker of the Legislature, said Friday is ongoing.
After conferring with law enforcement, the inspector general resumed its investigation into Doe’s death in April.
“The AG opinion did impact our investigation as much of our access to information and facilities was limited due to the actions taken after the opinion,” Koebernick said Friday.
The investigation concluded six months later with the full report and an Oct. 22 letter to Corrections Director Rob Jeffreys. The department’s chief inspector responded Nov. 4 on Jeffreys’ behalf and said he would consider the recommendations.