Audit of the Middlesex Sheriff’s Office—A Review of Healthcare and Inmate Deaths Objectives, Scope, and Methodology

An overview of the purpose and process of auditing the Middlesex Sheriff’s Office.

Overview

In accordance with Section 12 of Chapter 11 of the Massachusetts General Laws, the Office of the State Auditor has conducted a performance audit of certain activities of the Middlesex Sheriff’s Office (MSO) for the period July 1, 2021 through June 30, 2023. When designing the audit plan for examining employee settlement agreements entered into by MSO, we extended the audit period to July 1, 2018 through June 30, 2023.

We conducted this performance audit in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives.

Below is a list of our audit objectives, indicating each question we intended our audit to answer; the conclusion we reached regarding each objective; and, if applicable, where each objective is discussed in the audit findings.

Objective	Conclusion
Did MSO comply with and implement the requirements of Section 932.17(2) of Title 103 of the Code of Massachusetts Regulations (CMR) regarding the deaths of inmates in its custody?	Yes
Did MSO hold quarterly meetings with its contracted healthcare provider and review quarterly reports regarding inmates’ healthcare in accordance with 103 CMR 932.01(3)?	Yes
Did MSO administer mental health services to inmates in accordance with 103 CMR 932.13(1) and Section .08 of MSO’s “Policy and Procedure 613—Mental Health Services”?	Yes
Did MSO have internal policies and procedures in place for (a) the review and approval of employee settlement agreements, including the language used, and (b) the reporting of employee settlement agreements to the Office of the Comptroller of the Commonwealth (CTR)? For employee settlement agreements entered into from July 1, 2018 through June 30, 2023, did MSO follow these policies, and did it abstain from using non-disclosure, non-disparagement, or similarly restrictive clauses as part of employee settlement agreement language?	No; see Finding 2

To accomplish our audit objectives, we gained an understanding of the MSO internal control environment relevant to our objectives by reviewing MSO’s internal control plan and applicable policies and procedures, as well as by interviewing MSO’s management. We evaluated the design and tested the operating effectiveness of internal controls related to quarterly reports and inmate healthcare services. Specifically, we verified that quarterly reports were signed off by management upon review. We reviewed the initial medical screening records to determine whether all fields and sections of these records were filled out, whether there was a signed inmate consent and acknowledgement form, and whether there was a timestamped signature from the contracted healthcare provider who completed the initial medical screening records.

Note that we found an issue during our testing with Section .09(7) of MSO’s “Policy and Procedure 617—Procedures in the Event of Death or Serious Illness of an Inmate.” Namely, that MSO was unable to provide evidence of the approval of extensions for the completion of clinical mortality reviews. We noted that the policy does not contain requirements to document the approvals for extensions for the clinical mortality reviews. See Finding 1 for more information.

In addition, to obtain sufficient, appropriate evidence to address our audit objectives, we performed the procedures described below.

Inmate Deaths

To determine whether MSO complied with and implemented the requirements of 103 CMR 932.17(2) regarding the deaths of inmates in its custody, we took the following actions:

• We requested, and MSO provided us with, a list of any inmate deaths that occurred during the audit period while they were in MSO’s custody. This list included three inmates who died in custody.
• We interviewed MSO management regarding the deaths of inmates in its custody during the audit period and obtained MSO’s “Policy and Procedure 617—Procedures in the Event of Death or Serious Illness of an Inmate.”
• We inspected MSO’s “Policy and Procedure 617—Procedures in the Event of Death or Serious Illness of an Inmate” to determine whether it included the following requirements listed in 103 CMR 932.17(2):

1. internal notification to include medical and administrative staff;
2. procedures when discovering body;
3. disposition of the body;
4. notification of next of kin;
5. [Criminal Offender Record Information] notifications [sent to victim(s) of an inmate] as soon as practicable [when such notification is necessary];
6. investigation of causes;
7. reporting and documentation procedures;
8. procedure for review of incident by appropriate designated staff with a final report submitted to all appropriate parties.

• We examined the documentation related to the three in-custody deaths to determine whether in-house healthcare and administrative employees, as well as each inmate’s next of kin, were notified about each inmate’s death.
• We obtained and examined each inmate’s death certificate from the Office of the Chief Medical Examiner to determine whether MSO notified the Office of the Chief Medical Examiner about each inmate’s death.
• We examined each incident report to determine whether the disposition (or possession) of the body was moved to the appropriate authority (e.g., hospital morgue) and whether MSO notified the deceased inmates’ associated victims (if any) of the corresponding inmate’s death as soon as was practicable.
• We examined each investigative report, which included all corresponding incident reports, to ensure that the Internal Investigations Unit performed an investigation of the causes of the deaths.
• We examined the clinical mortality review document related to each inmate’s death to determine whether appropriate staff members, such as the healthcare unit administrator, superintendent, and special sheriff, reviewed the circumstances surrounding each inmate’s death and whether final reports were submitted to the special sheriff and chief legal counsel.

For this objective, we found that MSO complied with 103 CMR 932.17(2). 

Quarterly Meetings

To determine whether MSO held quarterly meetings with its contracted healthcare provider and reviewed quarterly reports regarding inmates’ healthcare in accordance with 103 CMR 932.01(3), we examined the minutes and attendance sheets (which were signed by meeting attendees) of all eight (100%) of the quarterly meetings that took place during the audit period between MSO and its contracted healthcare providers. In addition, we inspected all eight (100%) of the quarterly reports discussed in each of the quarterly meetings and all three (100%) annual statistical summaries that the contracted healthcare providers submitted to MSO during the audit period.

For this objective, we found no significant issues during our testing. Therefore, we concluded that, based on our testing, MSO met the relevant criteria regarding holding quarterly meetings with its contracted healthcare providers and reviewing quarterly reports regarding healthcare services for inmates.

Initial Mental Health Assessments

To determine whether MSO administered mental health services to inmates in accordance with 103 CMR 932.13(1) and Section .08 of MSO’s “Policy and Procedure 613—Mental Health Services,” we took the following actions. We interviewed personnel members from MSO’s in-house healthcare unit regarding the process of initial medical screening and mental health assessments. In addition, we selected a random, statistical¹⁵ sample of 72 inmates out of the population of 1,666 inmates at the Middlesex Jail and House of Correction (MJHOC) who were referred for further mental health assessments after their initial mental health assessment, using a 90% confidence level,¹⁶ a 50% expected error rate,¹⁷ and a 20% desired precision range.¹⁸ For our sample, we examined records from the inmate healthcare records management system for the dates of mental health referrals, dates of completed mental health assessments, whether the inmates needed further mental health assessments, and the names of the qualified mental healthcare professionals who conducted the assessments.

For this objective, we found no significant issues during our testing. Therefore, we concluded that, based on our testing, MSO met the relevant criteria regarding administering mental health services to inmates.

Employee Settlement Agreements

To determine whether MSO had internal policies and procedures in place for (a) the review and approval of employee settlement agreements, including the language used, and (b) the reporting of employee settlement agreements to CTR, we interviewed MSO’s chief legal counsel.

To determine whether MSO abstained from using non-disclosure, non-disparagement, or similarly restrictive clauses in employee settlement agreements entered into from July 1, 2018 through June 30, 2023, we obtained a list of all 32 employee settlement agreements (8 monetary and 24 nonmonetary) executed during the extended audit period. We also requested and reviewed the language in the associated employee settlement agreements, documenting any instances of restrictive language.

To determine whether MSO properly reported monetary settlements to CTR, we requested and reviewed copies of the employee settlement agreements. We determined whether the employee settlement agreements were signed by authorized representatives of both the employee and MSO. For the eight monetary settlements executed during the extended audit period, we determined whether the SJ Authorization Form detailed the terms of the settlement payment and was signed by MSO’s chief financial officer and MSO’s legal counsel. We also determined whether emails from CTR documented the review and approval of the settlement payment. These emails served as evidence that the required documentation was reported to CTR.

For the aspect of our objective regarding properly reporting monetary settlements to CTR, we concluded that, based on our testing, MSO met the relevant criteria. However, for other aspects of our objective—namely, MSO’s use of employee settlement agreements—we found certain issues during our testing. See Finding 2 for more information.

Data Reliability Assessment

Inmate Case Management System

To assess the reliability of the inmate data obtained from the inmate case management system, we interviewed the MSO information technology employees who oversaw the system. We tested the general information technology controls (i.e., access, configuration management, segregation of duties, contingency planning, and security management controls). In addition, we selected a random sample of 20 inmates from the list of 7,385 inmates who were in MSO’s custody during the audit period (which was extracted from the inmate case management system) and compared inmates’ information from this list (i.e., their full name, date of birth, and booking date) to the information in the original source documents (e.g., a mittimus or inmate property receipt) for agreement.

We selected a random sample of 20 hard copies of the mittimuses and compared inmates’ information from these mittimuses (i.e., full name, date of birth, and date of admission to MJHOC) to the information in the list of inmates from the inmate case management system for agreement. In addition, we tested the data for duplicate records. We reconciled the list of MSO’s in-custody deaths from the inmate case management system with the list provided to us by the Office of the Chief Medical Examiner.

Inmate Healthcare Records Management System

To assess the reliability of the inmate healthcare records obtained from the inmate healthcare records management system, we interviewed the MSO information technology employees who oversaw the system. We tested the general information technology controls (i.e., access, configuration management, segregation of duties, contingency planning, and security management controls). In addition, we selected a random sample of 20 records from the list of 6,733 inmate healthcare records from the inmate healthcare records management system and traced inmates’ information (i.e., inmate identification numbers and commitment dates) to the information on the list of inmates from the inmate case management system.

We selected a random sample of 20 inmates from the list of inmates from the inmate case management system and traced the inmates’ information (i.e., state identification number and commitment date) to that on the list of inmates’ healthcare records from the inmate healthcare records management system.

We were unable to identify a list of inmates who were referred to MSO’s in-house mental healthcare unit using the list of 6,733 inmate healthcare records. However, MSO was able to rerun the query of the inmate healthcare records management system to identify and extract a list of 1,666 mental health records during the audit period. To ensure the reliability of this list, we observed the extraction of the list and reviewed the query language to determine whether it included the data fields we requested. In addition, we selected a random sample of 20 inmate mental health records from the list of 1,666 inmate mental health records from the inmate healthcare records management system and traced the inmates’ information (i.e., state identification number and commitment date) to the information on the original list of 6,733 inmates’ healthcare records.

Employee Settlement Agreements

MSO provided us with a list of 32 employee settlement agreements executed during the extended audit period, July 1, 2018 through June 30, 2023. To ensure the accuracy of this list, we traced each employee’s name, settlement date, amount, and type of confidentiality language (e.g., non-disclosure or non-disparagement) included in the list to source documents (i.e., copies of the settlement agreement and the SJ Authorization Form). To ensure the completeness of the list of all eight monetary agreements executed during the extended audit period, we traced each employee’s name, date, amount, and funding source from CTR’s Settlements and Judgments Microsoft Access data to MSO’s employee settlement agreements list.

In addition, we obtained a list of the total population of 590 MSO legal expenses that MSO incurred during the extended audit period from CTR’s Commonwealth Information Warehouse.¹⁹ Using this list, we judgmentally selected a sample of 20 legal expenses, with the sample weighted to include 10 expenses from 2021²⁰ and 10 from the other four years from the extended audit period. We traced the legal expense information from this list (i.e., invoice date and amount) to hard copies of the legal invoices for agreement. In addition, we reviewed the legal invoices to determine whether they were related to employee settlement agreements.

We selected a random sample of 20 hardcopy legal invoices stored in MSO’s filing cabinets and traced the information on these invoices (i.e., vendor name, invoice date, amount, invoice number, and description of services) to the list of 590 legal expenses for agreement. In addition, we reviewed the legal invoices to determine whether they were related to employee settlement agreements.

Based on the results of the data reliability assessment procedures described above, we determined that the information we obtained during the course of our audit was sufficiently reliable for the purposes of our audit.

15.    Auditors use statistical sampling to select items for audit testing when a population is large (usually over 1,000) and contains similar items. Auditors generally use a statistics software program to choose a random sample when statistical sampling is used. The results of testing using statistical sampling, unlike those from judgmental sampling, can usually be used to make conclusions or projections about entire populations.

16.    Confidence level is a mathematically based measure of the auditor’s assurance that the sample results (statistic) are representative of the population (parameter), expressed as a percentage.

17.    Expected error rate is the number of errors that are expected in the population, expressed as a percentage. It is based on the auditor’s knowledge of factors such as prior year results, the understanding of controls gained in planning, or a probe sample.

18.    Desired precision range is the range of likely values within which the true population value should lie; also called confidence interval. For example, if the interval is 90%, the auditor will set an upper confidence limit and a lower confidence limit where 90% of transactions fall within those limits.

19.    The Commonwealth Information Warehouse contains budget, human resources, and payroll information, as well as financial transaction data from the Massachusetts Management Accounting and Reporting System.

20.    We selected 50% (10) of our sample from 2021 because the total dollar amount of legal expenses for that year was significantly higher than the other years in the extended audit period.

Date published:	December 19, 2025