Audit of the Middlesex Sheriff’s Office—A Review of Healthcare and Inmate Deaths Overview of Audited Entity

This section describes the makeup and responsibilities of the Middlesex Sheriff’s Office.

Overview

The Middlesex Sheriff’s Office (MSO) was established as an independent state agency on July 11, 1997, after Section 1 of Chapter 34B of the Massachusetts General Laws abolished Middlesex County as a form of government. This law was then amended by Chapter 61 of the Acts of 2009. According to Section 4 of Chapter 61 of the Acts of 2009,

All functions, duties and responsibilities of the office of a transferred sheriff pursuant to [the Act of 2009] including, but not limited to, the operation and management of the county jail and house of correction and any other statutorily authorized functions of that office, are hereby transferred from the county to the commonwealth.

The transition was completed on January 1, 2010. The Sheriff became an employee of the Commonwealth but remained an elected official and retained administrative and operational control over MSO. Under the Sheriff’s direction, superintendents administer MSO operations at MSO facilities.

According to MSO’s website, its mission statement is as follows:

The Middlesex Sheriff’s Office improves the quality of life by providing a safe and secure environment for staff, offenders and communities, working with our partners in law enforcement and criminal justice. We take pride in preparing offenders for re-entry by providing a comprehensive risk assessment and individualized treatment, educational, and vocational plans.

As of December 31, 2023, MSO had 641 employees. In fiscal year 2022, the annual state appropriation was approximately $71,996,127. In fiscal year 2023, MSO’s annual state appropriation was approximately $75,997,810.

MSO’s main administrative building is located at 12 Gill Street, Suite 4700, in Woburn. The Middlesex Jail and House of Correction (MJHOC) is located at 269 Treble Cove Road in Billerica. During the audit period, MJHOC had a total population of 7,385 inmates in its custody,¹ including 1,253 pretrial inmates, 4,678 sentenced inmates, 1,443 regionally arrested individuals,² and 11 individuals who were released before completing the booking process.³

Inmate Case Management System

MSO uses an inmate case management system to track and manage information on inmates in MSO’s custody. The information maintained in the system includes inmates’ names, genders, ethnicities, dates of birth, Social Security numbers, state identification numbers,⁴ booking numbers,⁵ booking dates, release dates, release types,⁶ and in-custody housing assignments.⁷ During the process of admitting an inmate, one of MSO’s booking officers enters information from a mittimus⁸ into the inmate case management system.

Inmate Healthcare Records Management System

MSO uses an inmate healthcare records management system, a web-based application, to record inmates’ health information, such as medical history, ongoing and past treatments, mental health conditions, medications, and scheduled appointments. Personnel members from MSO’s in-house healthcare unit also use the inmate healthcare records management system to document inmates’ medical requests.

Inmate Deaths

Section 932.17 of Title 103 of the Code of Massachusetts Regulations (CMR) requires agencies with county correctional facilities, such as MSO, to establish guidelines for notifications, investigations, reporting, and documentation regarding the deaths of inmates. According to Section .06 of MSO’s “Policy and Procedure 617—Procedures in the Event of Death or Serious Illness of an Inmate,” in the event of an inmate’s serious illness, injury, or death while in MSO’s custody, at least one of the officers on duty notifies the central control unit.⁹ This unit then notifies MSO’s in-house healthcare unit to assist, administer medical care, and/or provide transportation to the hospital, if appropriate. The first responder provides lifesaving assistance until personnel members from MSO’s in-house healthcare unit arrive.

In the event of an inmate’s death, the central control unit notifies the following parties of the inmate’s death: the Sheriff, the superintendent (or their designee) of the facility where the inmate was held in custody, the Security Investigations Unit, and the health services administrator.¹⁰ The superintendent (or their designee) notifies the following parties of the inmate’s death: the Massachusetts State Police, the Middlesex County District Attorney’s Office, the Office of the Chief Medical Examiner, and the inmate’s next of kin.

Once members from the Massachusetts State Police arrive at MJHOC, they, alongside the Security Investigations Unit, secure the scene of the incident and conduct an investigation to determine the cause and manner of death. The Office of the Chief Medical Examiner conducts a postmortem exam.¹¹ After this, the Office of the Chief Medical Examiner completes and signs the death certificate, then releases the body to the inmate’s next of kin.

Following the death of an inmate, each involved staff member must submit an incident report to one of MSO’s shift commanders (or their designee) by the end of their shift on the day of the incident. Personnel members from MSO’s in-house healthcare unit also complete a separate incident report through the inmate case management system medical notes section.

MSO’s assistant superintendent/director of security or its director of the Internal Investigations Unit (who reports to the special sheriff¹²) conducts an investigation of the death and secures the inmate’s living quarters, which they treat as a crime scene at this point. While these living quarters are considered a crime scene, an officer monitors and records any entries or other events until the investigation is complete, which happens after MSO has consulted with the Massachusetts State Police. Any inmates still living in the unit are temporarily relocated until the investigation is complete.

At the direction of the special sheriff, the assistant superintendent/director of security or the director of the Internal Investigations Unit conducts an investigation that may include a review of recorded videos, photographic evidence, and/or interviews of staff members or inmates. MSO must coordinate with the Middlesex County District Attorney or the Massachusetts State Police if either conducts an independent investigation. The assistant superintendent/director of security or the director of the Internal Investigations Unit submits the final report to the special sheriff.

After the death of an inmate, a contracted physician conducts a clinical mortality review,¹³ which must be completed within 30 days of the inmate’s death; however, the special sheriff may approve additional time for the clinical mortality review, if necessary. After the contracted physician completes the clinical mortality review, they must submit a report documenting this review to the special sheriff or their designee and MSO’s chief legal counsel.

Healthcare Services

During the audit period, the majority of healthcare services were provided by personnel members from MSO’s in-house healthcare unit. MSO also contracted with vendors for certain healthcare services, such as podiatry or dental services. MSO’s health services administrator was its health authority¹⁴ during the audit period, and was in charge of both (1) personnel members from MSO’s in-house healthcare unit and (2) healthcare service delivery for inmates. MSO also had an in-house mental health services department led by MSO’s director of behavioral health.

Quarterly Meetings

According to 103 CMR 932.01(3),

The county correctional facility [in this case, MSO] shall require that the health authority meet with the Sheriff/facility administrator or designee at least quarterly and submit the following:

1. quarterly reports on the health care delivery system and health environment; and
2. annual statistical summaries.

Quarterly reports, as referenced in the above regulation, cover topics such as risk management, infection control, inmate grievances, critical clinical events (e.g., instances of death or physical assault while providing healthcare), and medications that contracted healthcare providers currently administer to inmates. Statistical summaries, also referenced in the above regulation, contain data related to inmate health records and provide a comprehensive overview of medical services delivered to inmates during the year.

Initial Medical Screening

According to 103 CMR 932.06 and Section .10 of MSO’s “Policy and Procedure 601—Health Services,” personnel members from MSO’s in-house healthcare unit are required to perform an initial medical screening for each inmate upon admission to MJHOC. This occurs before an inmate is placed in MSO’s general population to ensure that each inmate’s health needs are identified and addressed. The initial medical screening consists of a questionnaire and observation to identify potential emergencies and to ensure that newly admitted inmates’ illnesses, health needs, and medications are identified for further assessment and continued treatment while in custody. A qualified healthcare professional records all findings resulting from the initial medical screening in the inmate healthcare records management system, which is then approved by the health authority.

Upon each inmate’s admission to MJHOC, personnel members from MSO’s in-house healthcare unit communicate (both verbally and in writing) to the inmate how they can access healthcare services. This communication may include special accommodations, such as the use of a translation service, to ensure that any inmate who may have difficulty communicating with employees understands how to access healthcare services.

Initial Mental Health Assessments

According to Section .07 of MSO’s “Policy and Procedure 613—Mental Health Services,” all mental health services are available for all MJHOC inmates if needed. A qualified healthcare professional performs an assessment of the inmate during the initial medical screening. If the qualified healthcare professional deems it necessary for the inmate to have their mental health evaluated based on the assessment, then the healthcare professional refers the inmate for further evaluation to a qualified mental healthcare professional. Initial mental health assessments must be completed within 14 days after an inmate’s admission to MJHOC. The initial mental health assessment consists of a questionnaire on suicidal ideation and acts of self-harm. If needed, a qualified mental healthcare professional observes the inmate to identify any potential mental health emergencies the inmate presents with when they arrive at the facility to ensure that the inmate’s mental health needs are identified for further assessment and continued treatment while in custody.

During the initial mental health assessment, if the qualified mental healthcare professional realizes that an inmate has a potential mental health risk, then this qualified mental healthcare professional discusses the case with the director of the Mental Health Services Department and may refer the inmate to a higher-level psychiatric facility, if necessary.

A qualified mental healthcare professional records the inmate’s evaluation data in the inmate’s electronic medical record in the inmate healthcare records management system.

State Employee Settlement Agreements

The Office of the Comptroller of the Commonwealth (CTR) has established policies and procedures for Commonwealth agencies processing settlements and judgments.

CTR’s “Settlements and Judgments” policy states,

A settlement or judgment results from a formal claim (grievance, complaint or lawsuit) against the Commonwealth that results in either a Settlement Agreement, or a court or administrative award, order or Judgment. . . .

A “claim” is considered any demand by any person for damages to compensate a wrong allegedly suffered, including but not limited to violation of civil rights, breach of contract, failure to comply with contract bidding laws, incorrect or improper personnel determinations regarding pay, promotion or discipline, failure to comply with statutory or constitutional provisions applicable to employment, an eminent domain taking, and attorney’s fees, interest and litigation costs associated with these claims.

For the purposes of our audit, we focused on settlement agreements resulting from claims brought by current or former state employees against MSO.

The procedures for agencies to determine availability of funds for the payment of settlements and judgments against the Commonwealth are described in 815 CMR 5.00, as are reporting requirements. This regulation requires agencies to prepare and submit a report to CTR’s general counsel before making the payment to ensure proper tax reporting. When reporting employee settlement agreements to CTR, state agencies use a Non-Tort Settlement/Judgment Payment Authorization Form (referred to in this report as the SJ Authorization Form) to document whether the claim will be paid by the agency or through CTR’s Settlement and Judgment Reserve Fund. This form also documents the type of claim (e.g., employment action, civil rights/discrimination, or awarded attorneys’ fees), agency information, the employee’s information, the type (e.g., lump sum, back pay, and/or interest) and amount of damages detailed in the settlement agreement, and the amount of any interest accrued. In addition to the SJ Authorization Form, agencies must also submit to CTR a copy of the employee settlement agreement signed by authorized representatives of both parties.

We found that MSO entered into 32 employee settlement agreements, totaling $2,182,451, during the extended audit period, July 1, 2018 through June 30, 2023.

1.    For an inmate to be in MSO’s custody means that MSO has authorization from a court to incarcerate an inmate until the court orders their release. A death in custody is one that occurs during this period of incarceration.

2.    A regionally arrested individual is a person who has been arrested by a law enforcement department from a county other than MSO’s. MSO’s facility holds the individual temporarily before they appear in court.

3.    These 11 individuals were released on bail before the booking process could be completed.

4.    A state identification number is a unique number assigned to each inmate in the criminal justice system.

5.    A booking number is a unique number assigned by MSO to an inmate upon their admission to MJHOC. A new booking number is generated upon every unique admission to the facility.

6.    The release type is the way in which an inmate is discharged from a facility, such as bail, parole, completion of their sentence, or death.

7.    A housing assignment is an inmate’s specific unit, cell, and bed within MJHOC.

8.    A mittimus is a written, court-issued document that follows an inmate through their time in the criminal justice system.

9.    The central control unit is a booth, operated by MSO employees, in the center of MJHOC. It is the central site of control for radio communication devices and physical access throughout all of MSO’s facilities. All communication into and out of MSO’s facilities goes through the central control unit.

10.    According to MSO’s “Policy and Procedure 601—Health Services,” the health services administrator is “that person, designated by the Sheriff, to oversee the management of the health care delivery system of the Middlesex Sheriff’s Office.”

11.    A postmortem exam is an examination of the deceased person’s body to determine the cause of death.

12.    The special sheriff oversees MSO’s Internal Investigations Unit and reports directly to the Sheriff.

13.    Section .05 of MSO’s “Policy and Procedure 617—Procedures in the Event of Death or Serious Illness of an Inmate” defines a clinical mortality review as, “An unbiased assessment based on all the facts and circumstances of the appropriateness of the clinical care to ascertain whether changes in policies, procedures, or practices are warranted, and to identify issues that require further study. The review shall be completed within thirty (30) days by a physician or designee selected by the Special Sheriff or designee, in conjunction with the Assistant Superintendent/Director of Security or the Director of the Internal Investigations Unit as directed by the Special Sheriff. The thirty (30)-day time frame may be extended with approval by the Special Sheriff. The review shall be documented, and a copy shall be provided to the Special Sheriff or designee and the Chief Legal Counsel.”

14.    According to 103 CMR 932.01, “The health authority may be a physician, health administrator, or health agency whose responsibility is pursuant to a written agreement, contract, or job description.”

 

Date published:	December 19, 2025