Edna Mahan Report of Investigation
Edna Mahan Report of Investigation
Prepared by:
June 3, 2021
TABLE OF CONTENTS
PAGE
II. Methodology............................................................................................................. 2
III. Background............................................................................................................... 4
V. NJDOC Policies and Typical Practice in Conducting Cell Extractions ................. 17
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I. INTRODUCTION
correctional officers and supervisors at the Edna Mahan Correctional Facility for Women
(“EMCF”) had been put on administrative leave, and a criminal investigation was
underway, after officers at the facility had been accused of severely beating several inmates
earlier that month. Subsequent media accounts stated that the brutality had taken place
during the process of corrections officers forcibly removing multiple inmates from their
cells shortly before midnight on January 11, through a process referred to as “cell
extraction.” EMCF inmates alleged that during that process, officers used excessive force,
resulting in serious physical injuries to multiple inmates. Additionally, one inmate made
ongoing investigation by the United States Department of Justice (“DOJ”) into sexual
abuse of inmates by EMCF officers. In April 2020, DOJ had issued a 29-page notice stating
that DOJ had reasonable cause to believe that the New Jersey Department of Corrections
(“NJDOC”) “fails to keep prisoners at Edna Mahan safe from sexual abuse by staff.”
On January 27, 2021, New Jersey Governor Phil Murphy announced that
Lowenstein Sandler LLP (“Lowenstein”) would undertake an investigation into the events
of January 11 “to determine how this happened and make recommendations to prevent
This report sets forth the results of Lowenstein’s investigation. Part II of the report
details the methodology used to conduct the investigation. Parts III, IV, and V provide
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background information, set forth applicable legal standards, and summarize relevant
NJDOC policies and procedures. Together, they provide historical and legal context for
our findings and recommendations. Part VI of the report sets forth our detailed findings
and analysis regarding the cell extractions and the response by State officials. Part VII
contains our conclusions and recommendations to address the issues identified in the
II. METHODOLOGY
Lowenstein’s investigation team was led by former New Jersey State Comptroller
and federal prosecutor Matthew Boxer, Esq. The other principal members of the
investigation team were Rachel Moseson Dikovics, Esq., Jamie Gottlieb Furia, Esq.,
Rasmeet K. Chahil, Esq. and Amanda K. Cipriano, Esq., who managed many of the
investigative steps.
NJDOC fully and without exception cooperated with the investigation in making its
officials available for interviews and promptly supplying Lowenstein with all requested
correspondence requested from NJDOC and the Office of the Corrections Ombudsperson,
an office housed outside of NJDOC that is charged with protecting against improper
treatment of inmates in NJDOC’s custody. The reviewed materials included, for example,
incident reports, records of disciplinary action related to the cell extractions, disciplinary
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management procedures, attendance records, NJDOC organizational data, and email
online sources, and other third-party sources, some of which was unsolicited, including
The methodology for this report also included statutory research, review of
applicable legal standards and best practices, and review of legislative testimony and
related documents. In addition, Lowenstein reviewed all available video footage relating
to the January 11 cell extractions, totaling more than 20 hours of recordings. The contents
NJDOC Commissioner Marcus Hicks, NJDOC Chief of Staff Victoria Kuhn, NJDOC’s
DiBenedetti, Governor Phil Murphy and several senior officials in the Governor’s Office,
Keller, and other present and former NJDOC officials. Additionally, we interviewed
EMCF inmates, the President of the Policemen’s Benevolent Association Local Number
105, criminal justice consultants, and a human rights advocate on behalf of prisoners.
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In the course of our work, we were careful to avoid interference with the substantial,
ongoing criminal investigations being led by the Office of the New Jersey Attorney
by law enforcement affected the timing of our investigation and significantly limited the
information regarding those individuals and their version of events from, for example,
narratives from officer disciplinary proceedings and inmate disciplinary proceedings, their
emails, written statements provided to other authorities, other written narratives and
reports, video evidence and other sources. The evidence we obtained provides an
Lowenstein attorneys also visited EMCF to inspect the unit within South Hall on
the maximum security compound where the January 11 cell extractions were conducted.
During our visit, we questioned EMCF administrators and custody staff, examined
III. BACKGROUND
A. The Facility
population. The facility opened more than 100 years ago, in 1913, as the “State
in the minimum security complex and 278 in the maximum security complex.
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EMCF has a total staff of 462, including 361 custody staff and 101 civilian staff.
Of those, 166 custody staff are female (46 percent) and 51 civilian staff are female (50
percent). Among the civilian staff are various administrators and mid-level supervisors.
EMCF is run by an “Administrator,” which is the term used in New Jersey correctional
facilities for the person more commonly known as a “warden.” EMCF’s current
security area, and in some respects resembles a college campus more than a typical prison.
It includes five operating buildings. Minimum security prisoners have relative freedom of
movement within their housing units and, to some extent, within the compound. In
contrast, the maximum security compound is fully fenced and includes eight operating
housing units, including the South Hall compound, which contains seven individual sub-
units.
Within the South Hall compound is the Restorative Housing Unit (“RHU”), a close
custody unit separate and apart from the general prisoner population, where prisoners are
placed because of disciplinary infractions. See N.J.A.C. 10A:5-9.5. The RHU is intended
monitored and documented by a team of custody and civilian staff.” N.J.A.C. 10A:5-9.2.
EMCF’s RHU was established through NJDOC policy in August 2020, following the July
2019 passage of the Isolated Confinement Restriction Act, N.J.S.A. 30:4-82.5–82.11. The
RHU’s physical location existed before that time, having been referred to, for example, as
Administrative Segregation.
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As NJDOC Commissioner Marcus Hicks described in his investigative interview,
infractions. Prisoner activity within the unit is more restricted than in the general facility
population, but unit conditions are less restrictive than in what NJDOC policies refer to as
the “Adjustment Unit.” NJDOC policy states that inmates in RHU “shall not have their
including recreational time, commissary access, “JPAY” access (an email and grievance
system used by New Jersey correctional facilities) and phone calls. See N.J.A.C. 10A:5-
9.2. EMCF’s RHU includes 20 maximum security cells, most of which have the capacity
Aside from custody and civilian staff, also working at EMCF are members of
conduct is at issue, working with law enforcement to investigate. See N.J.A.C. 10A:1-2.2.
All NJDOC SID investigators are former custody staff. In addition to the standard 14-
week training course completed by New Jersey correctional officers at the NJDOC
course.
by Chief Duane Grade, who reports directly to Commissioner Hicks. Three Deputy Chiefs
report to Grade. Each correctional facility’s SID investigators report to an on-site principal
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investigator who, in turn, reports to an SID Deputy Chief. EMCF’s SID team includes
B. A Troubled History
In recent years, numerous EMCF custody and civilian staff members have been the
consent to sexual activity with custody or civilian staff of correctional facilities. N.J.S.A.
2C:14-2(c)(2). Between 2016 and 2018, seven EMCF employees – correctional officers
Brian Ambroise, Ronald Coleman, Anhwar Dixon, Jason Mays, Joel Mercado and Thomas
Seguine, and civilian staff member Joel Herscap – were charged with crimes relating to
sexual abuse of EMCF prisoners, including sexual assault, conspiracy to commit sexual
assault, criminal sexual contact and official misconduct. All but Ambroise, who was found
not guilty at trial, and Coleman, who has not yet been tried, have pled guilty or have been
found guilty at trial, and have been sentenced. Mays was sentenced to sixteen years in
prison; Dixon was sentenced to five years in prison; and Herscap, Mercado and Seguine
each were sentenced to three years in prison. In 2019, another EMCF correctional officer,
Ciera Roddy, was charged with crimes including official misconduct and criminal sexual
contact, and Lieutenant Jose Martinez was charged with witness tampering. Roddy pled
guilty and was sentenced to 90 days in jail. Martinez has not yet been tried.
In response to the above, on April 26, 2018, DOJ initiated an investigation of EMCF
pursuant to the Civil Rights of Institutionalized Persons Act, 42 U.S.C. § 1997 et seq., to
whether EMCF was able to protect prisoners from sexual abuse. In July 2018, DOJ
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attorneys and experts conducted a four-day on-site review of EMCF. In April 2020, DOJ
As noted by Commissioner Hicks in recent testimony before the New Jersey Senate Budget
Committee, the State has reached a tentative agreement with DOJ on the terms of a
settlement, which NJDOC anticipates will include oversight of EMCF by a federal monitor.
The above conduct also has resulted in civil lawsuits, including against NJDOC
itself. In April 2021, NJDOC settled a class action lawsuit brought by more than 20 current
and former EMCF inmates, which alleged sexual abuse by correctional officers at the
facility dating back to 2014. The settlement’s publicly disclosed terms include a $20.8
C. Remedial Efforts
In the time since the arrests described above, NJDOC has undertaken various efforts
1. External Advice
In 2017, NJDOC began to use external experts to guide and assist its efforts to
improve policies, procedures and conditions at EMCF. For example, it engaged a team of
consultants from the National Institute of Corrections (“NIC”), which is an agency within
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the Federal Bureau of Prisons, to conduct an assessment of EMCF and provide advice. The
team of four NIC consultants was led by a criminal justice expert who specializes in sexual
NJDOC should institute gender-responsive training, which NIC consultants later provided
to EMCF supervisors.
Since 2016, NJDOC has been attempting to overhaul EMCF’s camera surveillance
system. Prior to these efforts, there were 45 federally funded cameras at the facility.
Between 2016 and 2019, 183 additional cameras were installed to reduce “blind spots”
believed to have contributed to instances of sexual abuse. These 183 cameras were
temporary measures, installed to provide adequate surveillance while the camera system
An outside engineering firm was hired to redesign EMCF’s camera system, and the
firm held its final design meeting with NJDOC in March 2019. The expansion and upgrade
project is being rolled out in phases. According to NJDOC, once it is complete, there will
be a total of 634 cameras at the facility. As of January 11, 2021, 99 cameras had been
installed, and from January 11 to April 30, 2021, 153 additional cameras were installed,
bringing the total upgraded cameras at the facility to 252. The project is estimated to be
delayed because of Covid-19. The delays in camera implementation and their impact are
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3. Female Leadership and Staffing
Beginning in September 2017, NJDOC appointed women to fill three critical roles
at EMCF that previously were held by men: at that time, Sarah Davis was appointed
Administrator; in June 2018, Renee Carr-Foster was appointed SID Principal Investigator;
and in August 2018, Robin Keller was appointed as Compliance Coordinator to oversee
the facility’s compliance with the federal Prison Rape Elimination Act, 34 U.S.C. § 30301
(“PREA”). PREA is a 2003 federal law that resulted in a series of detailed federal
The number of female officers at EMCF also has increased in recent years. In 2015,
EMCF employed 124 female custody staff. As of March 2021, the facility employed 166
female custody staff. The increase in female officers was accomplished, in part, through
“gender-restricting” certain custody posts at EMCF, meaning that they must be occupied
by female officers, or, in some cases, that a minimum number of female officers occupy a
particular post at all times. For example, roles requiring officers to conduct frequent inmate
strip searches are gender-restricted to female custody staff. In August 2018, EMCF
restricted to female officers only. A total of 55 posts (split between three work shifts) are
4. Training Efforts
NJDOC also enhanced the training it provides to custody staff as it relates to PREA
and the prevention of sexual assault. In 2018, the NJDOC Office of Training created a new
gender-responsive training module based on the NIC’s supervisor training, and all EMCF
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custody and civilian staff, as well as NJDOC officials and transportation staff who interact
with EMCF inmates, received that training. Additionally, in May 2019, NJDOC’s
executive staff, along with a group of EMCF supervisors, attended a three-day NIC training
NJDOC also expanded and updated its training on undue familiarity between
officers and inmates. Additionally, NJDOC added a sexual assault prevention training,
which was developed in consultation with the CLEAR Law Institute, to its standard officer
training.
D. New Legislation
Attempted remedial steps at EMCF have included legislative efforts as well, which
followed multiple rounds of legislative hearings that included testimony from inmate
advocates and former EMCF inmates. For example, the Isolated Confinement Restriction
Act, which limits the use of solitary and isolated confinement in New Jersey’s correctional
facilities, was signed into law in July 2019. The law provides that “[i]solated confinement
should only be used when necessary, and should not be used against vulnerable
more per day . . . with severely restricted activity, movement, and social interaction.”
N.J.S.A. 30:4-82.7. The privileges and movements of inmates in EMCF’s RHU are not
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In January 2020, the Dignity for Incarcerated Primary Caretakers Act was signed
into law. It had two primary purposes: increasing services for inmates who are parents,
and significantly expanding the authority and responsibilities of the Office of the
hearings; and otherwise ensuring correctional facilities’ compliance with relevant laws,
Despite these expanded powers, our investigation found that the OCO’s practices have not
significantly changed since the law was passed. For example, although OCO has subpoena
power, it has not yet been exercised, and unscheduled correctional facility inspections
began only recently. This may be at least partially due to staffing issues; until recently,
there were only two Assistant Ombudspersons who, together with Ombudsperson Dan
DiBenedetti, were responsible for independent oversight of all correctional facilities in the
state. In early March 2021, four additional Assistant Ombudspersons were hired. In our
interview with DiBenedetti, who has announced he will retire this August, he told us that
even with these additions, his office is understaffed relative to the scope of its
contacts in one day, and he stated that OCO was not finding it possible to keep up with that
volume.
On January 21, 2020, three bills that pertain to correctional facility training
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searches were signed into law. The first, codified at N.J.S.A. 30:1B-6.13-14, mandates 20
hours of in-service training for every correctional officer in each facility, in addition to
least four must be comprised of training on “(1) sexual assault, sexual abuse, and sexual
fraternization and undue familiarity; and (3) conditioning and manipulation awareness.”
correctional facilities to report inmate abuse and provides for the establishment of an abuse
reporting program for corrections employees. It mandates that all correctional facility
employees “shall” report “in a timely manner” any suspicion or belief “that an inmate is
being or has been abused by any other employee.” N.J.S.A. 30:1B-40(a). The statute
prevents disclosure of the identity of the reporter, unless disclosure is otherwise required
by law, and also immunizes from civil or criminal liability and protects from retaliation
any person who makes a report under the law and/or testifies in relation to the report.
disciplinary action against anyone who fails to make a required report. N.J.S.A. 30:1B-43.
policy “to limit cross gender searches and surveillance” in New Jersey correctional
facilities. The law mandates that only specially trained, same-gender officers may perform
officers are also prohibited from viewing different-gender inmates who are nude or using
the toilet except in emergency or extraordinary circumstances. This statute lines up with
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PREA requirements, see 28 C.F.R. § 115.15, with which correctional facilities must also
abide.
Despite the above efforts, on the night of January 11, 2021, a series of cell
extractions were so mishandled as to result in the injury of multiple inmates and the
ultimate suspension of 34 EMCF supervisors and staff. The next few sections of this report
set forth the standards that apply to a forced cell extraction and line up those standards
Title 10A of the New Jersey Administrative Code governs the functions of
“mechanical force.” N.J.A.C. 10A:3-3.3(b). “Physical force” may include, for example,
“wrestling a resisting individual to the ground, using wrist locks or arm locks, striking with
10A:3-3.3(b)(1). “Mechanical force” “means the use of some device or substance, other
than a firearm, to overcome an individual’s resistance,” such as the use of pepper spray.
N.J.A.C. 10A:3-3.3(b)(2).
“Cell extractions” are not defined in Title 10A, but generally entail the removal of
an inmate from her cell by an extraction team, the members of which typically wear
protective equipment and utilize body shields, and may employ chemical agents like pepper
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spray. Cell extractions may be carried out without the use of force if an inmate is
compliant, but a forced cell extraction inherently involves “use of force” and is subject to
Title 10A provides that non-deadly force by custody staff may be justified by
facility regulations,” or “in situations where a custody staff member with the rank of
Sergeant or above believes that the inmate’s failure to comply constitutes an immediate
10A:31-8.18(a)(5).
The regulations state that custody staff members are empowered to “use the amount
of force reasonably necessary to accomplish the law enforcement objective,” subject to the
following: (1) custody staff must use “the minimum force possible that is objectively
reasonable under the totality of the circumstances”; (2) “as soon as the individual submits,
the custody staff member shall reduce the degree of force used”; and (3) there are no
N.J.A.C. 10A:31-8.17(d), (e), (g). Custody staff is “encouraged to interrupt the flow of
events to help ensure that a fellow custody staff member does not resort to employing an
staff involved in a use-of-force incident are required to write a report of the incident and
must “be prepared to justify the use of physical force.” N.J.A.C. 10A:31-8.17(f), (h).
officer. Force used must be “objectively reasonable” under the Fourth Amendment to the
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Constitution, Graham v. Connor, 490 U.S. 386, 396–97 (1989), and must not constitute
cruel and unusual punishment under the Eighth Amendment. See, e.g., Brooks v. Kyler,
204 F.3d 102, 106 (3d Cir. 2000). The United States Supreme Court has set forth factors
to determine whether a correctional officer’s use of force was “excessive and unjustified.”
(1) “the need for the application of force”; (2) “the relationship
between the need and the amount of force that was used”; (3)
“the extent of injury inflicted”; (4) “the extent of the threat to
the safety of staff and inmates, as reasonably perceived by
responsible officials on the basis of the facts known to them”;
and (5) “any efforts made to temper the severity of a forceful
response.”
Id. (quoting Whitley v. Albers, 475 U.S. 312, 321 (1986)). The Supreme Court has
courts must examine “whether force was applied in a good faith effort to maintain or restore
discipline or maliciously and sadistically for the very purpose of causing harm.” Whitley,
In December 2020, New Jersey Attorney General Gurbir Grewal issued a directive
(the “Directive”) to all New Jersey law enforcement agencies regarding their use-of-force
policies, based on several “core principles.” Three of those principles are especially
relevant to our inquiry: (1) the duty to de-escalate and use force as a “last resort”; (2) the
“duty to use only objectively reasonable, necessary, and proportional force”; and (3) the
“duty to intervene and report.” Whether NJDOC correctional facilities are technically
subject to law enforcement directives from the Attorney General is a subject of some
debate, but in any event the NJDOC officials we interviewed informed us that the Directive
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has been adopted by NJDOC as a “best practice.” An explanation of the NJDOC and
EMCF policies and procedures that attempt to effectuate the above standards follows in
Part V.
NJDOC policies recognize that “[t]here will be occasions when it will be necessary
to force an inmate to move from one cell and/or area to another cell and/or area.” However,
conducting multiple cell extractions at the same time, as occurred here, is rare. Now-retired
EMCF Administrator Sarah Davis told us that she could not recall an instance at EMCF
when more than one cell extraction was conducted at one time, let alone across an entire
According to NJDOC records, there were 21 events at EMCF between May 2018
and April 2021 that NJDOC considers cell extractions. Seventeen of those involved the
use of force and four did not. In all NJDOC facilities, there were a total 275 cell extractions
There is an NJDOC policy that specifically governs cell extraction procedures, titled
“Use of Force and Security Equipment: Forced Cell Extraction.” The policy states that
custody staff members may only use force that is “objectively reasonable and necessary”
and that “the utmost restraint should be exercised and the use of force [should] never [be]
considered routine.”
Along those lines, former EMCF Administrator Davis told us that a cell extraction
should occur only after de-escalation attempts fail. From her perspective, cell extractions
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are an “absolute last resort.” She explained that she preferred to talk to the inmate so the
situation “would abate itself.” Davis stated that she would also try to find a staff member
who had a positive rapport with the inmate to intercede. Davis said that most cell
extractions were related to inmate mental health issues. She said that when there is a cell
extraction, the officers “suit up” in protective gear and once an inmate sees the team at her
door, the inmate often has a change of heart and complies with the order at issue.
Consistent with that approach, NJDOC policy states that as long as “there is no
immediate danger to the inmate’s safety, or serious damage to state property by the inmate,
a reasonable amount of time will be allowed for the inmate to comply.” The policy states
that “compliance” at this stage “means the inmate removes all clothing (strips) and places
his or her hands through the food port (if applicable) so that he or she can be handcuffed.”
(We were told in multiple investigative interviews, however, that at EMCF, inmates are
generally strip searched after being moved to another cell, as opposed to in their own cell
before moving. In any event, whenever the inmate is strip searched, she is permitted to re-
dress before leaving the cell.) Davis stated that after arriving at an inmate’s cell, the
officers should use “constructive force” to verbally coax the inmate by telling her that if
she does not come out of the cell, the officer will deploy pepper spray. Davis further stated
that when “constructive force” does not work, deployment of pepper spray is the next step,
One issue that arose with respect to the cell extractions that took place on January
11 is whether proper authorization protocols were followed. NJDOC policy itself is not
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entirely clear as to the required approval of a cell extraction, particularly as to whether
While one senior NJDOC official we interviewed suggested that Central Office has
to approve all EMCF cell extractions, and there has been legislative testimony to that effect,
NJDOC policy states that a “senior custody supervisor in conjunction with the facility
Major and Administrator” has the authority to make a decision on the use of force in the
case of a cell extraction. Similarly, though not identically, State regulations indicate that
any sergeant or higher-ranking official may authorize non-deadly force, which would seem
NJDOC Central Office in either the policy or the regulations. Along these lines, former
Administrator Davis stated to us that she did not typically seek approval from Central
Office to conduct cell extractions, because cell extractions are generally “urgent
situation[s].” The current Administrator at the facility, Patricia McGill, stated to us that
she personally prefers to “get clearance” if possible, but that seeking permission from
on “third shift,” which is the overnight shift between 10:00 p.m. and 6:00 a.m., is highly
disfavored. For example, EMCF Assistant Superintendent Robin Keller stated that she was
taught not to do cell extractions on the third shift unless “absolutely emergent,” such as if
an inmate has a weapon or is self-injurious. She explained this is because there is only a
“skeleton staff” at the facility on the overnight shift and if anything goes wrong, there is
not enough staff to respond. A former high-ranking NJDOC official we interviewed put it
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more bluntly, stating that a cell extraction taking place at this time of night “is for one
reason: there are fewer people around and fewer eyes.” That official said to empty an entire
restrictive housing area in the middle of the night is “extremely unusual” and “outside of
normal practice.”
Commissioner Hicks stated to us that last year, NJDOC Central Office verbally
communicated a directive to all facility administrators that cell extractions should not be
conducted on third shift, and if an administrator felt a cell extraction was necessary on third
shift, they would need approval from Central Office. According to Commissioner Hicks,
as part of his reform efforts at EMCF, he had streamlined the NJDOC reporting line as it
take place at EMCF, Deputy Commissioner Ricci would personally need to provide
approval.
This third-shift approval directive was not provided in writing or via email, and its
parameters are not entirely clear. Commissioner Hicks stated to us that his understanding
is that the approval or denial should happen verbally, through dialogue between the facility
Commissioner Hicks stated that when extraction approval is sought and provided,
the Deputy Commissioner usually will notify him, but cell extractions can take place
without him knowing. He stated that if a cell extraction happens with no issue or injury,
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he probably would learn about it through reading reports or during staff meetings. If there
immediate preliminary inquiry, and if the event is determined to have disrupted or have the
potential to disrupt the “secure or orderly operation of the correctional facility,” the
Operations by telephone and explain what happened and who was involved. N.J.A.C.
10A:21-5.1–5.2. However, SID Chief Grade reported to us that, in practice, SID generally
NJDOC policy sets forth in detail how a cell extraction, once authorized, is to be
conducted. Significantly, the policy states that once an extraction has been approved, “all
custody activity regarding the move shall cease pending arrival of a custody supervisor
with a video camera.” Even if the inmate changes her mind and agrees to comply with the
move at this time, the move may not be made until it can be video recorded. The person
recording the cell extraction must be a supervisor at the level of sergeant or above. Once
the assigned supervisor handling the video recording arrives, he or she must turn the camera
on and verbally announce the date, location, inmate involved and nature of the incident to
be recorded. After receiving the supervisor’s briefing, the extraction team members are to
announce their names on camera. The camera must be used to record the entire incident.
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The video recording should not stop “until the inmate(s) involved have been placed in
mechanical restraints, examined by the medical department and secured in a cell and/or, if
The extraction team is to consist of five officers, each of whom is assigned a specific
member-number and responsibilities. Each officer assigned to the team must wear
protective equipment, including a helmet with a face shield, riot jacket with groin protector,
1. “Team Member #1 is responsible for pinning the inmate against the furthest
wall or floor if the inmate falls or lies down, using the shield as protection
from bodily fluids and/or weapons.”
3. “Team Member #3 is responsible for securing the inmate’s arm on the left
side . . . and applying the handcuffs.” Once the handcuffs have been secured,
Team Member #3 must loudly announce “Hands Secured.”
4. “Team Member #4 is responsible for securing the inmate’s leg on the right
side . . . and assisting with rolling the inmate over if necessary for the
application of mechanical restraints.”
5. “Team Member #5 is responsible for securing the inmate leg on the left
side” and is to place “the leg irons on the inmate with the assistance of Team
Member #4 and, after completing the application of the leg irons, announce
loudly ‘Legs Secured.’”
The policy specifies the role of each of the five team members for each subsequent
step in the extraction process as well. Each extraction is to be handled individually, and
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Immediately following any instance of physical force being used, “each staff
member who participated in or witnessed the event” must submit a written report to the
shift commander. The report must contain, among other things: a description of the events
leading up to the use of force; the reason for employing force; and a description of the
Cell extractions include a physical search of the inmate. As per NJDOC policy,
Consistent with the comments above regarding conducting multiple cell extractions,
interviewees reported to us that a search of an entire housing unit at one time, as occurred
on January 11, is rare. Commissioner Hicks stated that searching an entire housing unit at
one time does not happen “unless we have evidence or intelligence that the entire unit has
do an extraction, it’s one cell. Search is one cell. To do an entire housing unit is rare.”
NJDOC policy does provide for “mass search” events, which, as Commissioner Hicks
noted, may be predicated on “specific information” received from a third party or based on
Searches conducted in conjunction with a cell extraction may result in the seizure
of contraband, which NJDOC policy defines, in part, as “[a]ny article, which may be
harmful or presents a threat to the security and orderly operation of the correctional
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facility.” The policy states that “[w]henever an item, article or material is determined to
This section of the report provides our investigative findings and analysis related to
the January 11 cell extractions. Our overview of the facts proceeds chronologically and
focuses on three main subjects: conditions and oversight at EMCF in the months leading
to January 11; the cell extraction incident; and the response to the incident.
In the latter part of 2020, there were changes at EMCF that ultimately contributed
1. Facility Oversight
In late 2020, leadership at EMCF was in a state of transition. Earlier that year, the
on-site SID Principal Investigator had retired. Then, on August 26, 2020, Sarah Davis, the
facility Administrator, filed for retirement with the State’s Division of Pensions & Benefits,
to begin in early 2021. NJDOC informed us that they received notification of that filing in
October 2020. NJDOC records indicate that the last day Davis actually was present at
EMCF was October 29, 2020. After that date, she used accumulated leave time until her
EMCF as “abrupt.” He said that while NJDOC leadership knew she intended to retire, they
did not know exactly when her leave would begin, and he said that when she did ultimately
give notice, it was less than two weeks before she physically departed the facility. Davis
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sees it differently, telling us that she provided notice in the beginning of October, which
Davis said was a typical amount of notice for a supervisor to provide. She stated that it
In any event, NJDOC appears to have been caught flat-footed in response to the
departure of the lead official, and someone brought in as a key reformer several years prior,
at its most troubled facility. NJDOC publicly posted the available Administrator position
at EMCF on October 16, 2020. That position ultimately was filled by current
Administrator Patricia McGill, whose first day at EMCF was January 16, 2021.
Our investigation revealed that between Davis’s last day at EMCF on October 29
and McGill’s appointment after the January 11 cell extractions, there was no Acting
told us that their understanding was that Erica Stem was the Acting Administrator at the
facility beginning in late November 2020. However, others, including Stem herself and
the NJDOC Chief of Staff, told us that Stem was transferred to EMCF as an Associate
Administrator and remained in that title, not Acting Administrator. State personnel records
reflecting Stem’s assignment to EMCF confirm that she was transferred as an Associate
Administrator and do not suggest that her title changed upon her transfer. In our
investigative interview, Stem told us that she was not given any specific reason for her
reassignment to EMCF, and confirmed that no one ever told her she would serve as Acting
Administrator, and that she did not, in fact, serve in that capacity.
-25-
November 24 or 25, 2020. Until that point, EMCF had one Associate Administrator, Sean
St. Paul. Commissioner Hicks told us that St. Paul would have reported to Stem upon her
arrival at EMCF, but our investigation determined that St. Paul and Stem operated with
Stem and St. Paul worked together to run EMCF from late November 2020 until
McGill’s appointment on January 16. However, Stem was on leave and away from the
facility from January 4 through January 12, 2021. Thus, on the night of January 11, St.
Paul had oversight of EMCF. Both Stem and Davis stated to us that no one at the facility
was reporting to them while they were on leave; any issues would have been reported to
St. Paul.
especially in the RHU. At that time, the RHU housed a number of inmates described by
that because of the Covid-19 pandemic, other units within the South Hall compound that
previously were allocated for disciplinary housing had been converted to isolation and
quarantine wings, so RHU was limited to a single long hallway of cells. That made it
difficult or impossible to separate inmates who do not get along well with each other,
term used to refer to an inmate squirting a correctional officer with liquid, often urine or
-26-
emergency from an operational perspective (i.e., it is not something that requires an
immediate security response), but it constitutes a health emergency for the officer who is
splashed, particularly in the context of the Covid-19 pandemic, and that it “needs to be
reported.” Splashing is a form of assault. Splashing incidents are reported to SID, then
referred to county prosecutors. However, they are rarely if ever criminally prosecuted,
according to NJDOC officials and others we interviewed. Instead, inmates may receive
administrative disciplinary charges, which frequently result in their RHU sanctions being
extended, such that they remain for a longer period in the location in which their
SID Chief Grade told us that “assaulting officers with liquids” is a common problem
in correctional facilities across the state, though some administrators and inmates we
interviewed indicated that splashing is relatively new at EMCF. They said that RHU
inmates have learned various splashing techniques from inmates recently transferred to
EMCF from other facilities, where splashing of officers is more common. EMCF
administrators we interviewed said that splashing was occurring three to four times per
The RHU cells have doors that are a few inches thick, and each door has a window
and a food “port” or opening. The doorways are narrow, but there is a gap where the door
meets the wall that is a few centimeters wide. As one method of splashing, inmates
allegedly began affixing part of a hollowed-out pen to an empty shampoo bottle filled with
fluids, then, using that converted bottle, squirted liquids at officers through the gap between
the cell door and the wall. In our interview with Administrator McGill, she said that during
-27-
staff tours of RHU, inmates would throw “feces, urine, water, milk – you name it” at staff,
and that because of the layout of the RHU hallway, staff might be splashed from multiple
angles at the same time. EMCF supervisors reported to us that in the days preceding
January 11, there was a coordinated effort by RHU inmates to splash officers.
All of this contributed to substantial frustration on the part of EMCF officers, who
were upset that, in addition to the fact that inmates were not being criminally charged for
splashing, the disciplinary charges they received were downgraded in some cases. We
were told that officers felt that inmates were not being held accountable for their actions
and that their supervisors were not protecting them. As the officers’ union president put it
to us, “things reached a boiling point.” Compounding all of that was the stress caused by
the Covid-19 pandemic. EMCF officials we interviewed stated that custody staff was
frustrated and exhausted, and felt unsupported, and that there was heightened emotion
among staff as a result. One supervisor summarized things by saying that the RHU was
NJDOC Central Office officials apparently were not made aware of any increase in
splashing incidents at EMCF. For example, Commissioner Hicks told us that he does not
recall receiving any reports of inmates splashing liquids at weekly briefings during that
time.
Beginning on the night of January 11 and extending into the early morning hours of
January 12, 2021, a series of cell extractions were conducted in the RHU. Below, we detail
facts about the extractions chronologically, breaking the incident into three phrases: the
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decision to conduct cell extractions; the extent to which authorization was sought; and the
extractions themselves.
officer conducted a search of Inmate 4’s1 RHU cell while she was not inside it; at that time
she was in the “RHU module,” where RHU inmates can access JPAY tablets and have
recreational time. A “contraband seizure” form indicates that a conditioner bottle with an
“inmate pen” attached to it was seized from the cell. The form attached a photograph of
Three splashing incidents occurred shortly after the search of Inmate 4’s cell. First,
at approximately 5:39 p.m., during service of evening “mess” (dinner) in the RHU, Inmate
4 sprayed a correctional officer with an unidentified liquid through the gap between her
cell door and the wall. The officer sprayed was the same one who had just conducted the
1
Because of the sensitive nature of the facts at issue, we have used numbers as opposed to names of inmate/victims.
-29-
search of Inmate 4’s cell. According to the officer’s report, the liquid struck her in her
right eye, went down the right side of her face, onto her shoulder, and down her back. She
stopped the mess movement on the wing, notified the area sergeant and went to receive
medical attention. The sergeant’s incident log report states that Inmate 4 “still retains the
NJDOC disciplinary records show that this was not the first time that Inmate 4 had
been accused of splashing officers. She had been disciplined for “throwing bodily fluids”
Documents indicate that the evening mess in the RHU resumed at 7:37 p.m. During
this second attempt to serve the meal, Inmate 1 “began spraying an unknown liquid out the
side of her cell door attempting to hit” the officer serving mess and two other correctional
officers who accompanied her. Mess service was again halted at that time.
front of Inmate 1’s cell to screen themselves from further splashing. Nonetheless,
according to the officers, Inmate 4 splashed an officer on the arm while he was in the
process of placing the shield. A second correctional officer reported that at the same time,
Inmate 1 splashed him with an “unknown clear liquid” while he was attempting to place
the shield. A third officer claims to have been hit on his face, including his eyes, with an
unknown substance. The officer who allegedly was hit in the eyes received outside medical
attention; the other two officers declined medical attention. Video footage we reviewed
from a fixed camera in the RHU confirmed that at approximately 8:30 p.m., liquids were
-30-
expelled from at least two cells while four correctional officers attempted to place rolling
During these events, on-site officers were providing updates to facility supervisors.
Associate Administrator St. Paul subsequently drafted an email summarizing that dialogue.
His narrative largely tracks those of other supervisory reports that were filed. It states that
a facility major contacted him and informed him that “approximately five officers were
assaulted.” The narrative states that St. Paul and another supervising officer decided they
needed to “take a ride to EMCF.” Upon their arrival, they were briefed and informed that
suited extraction teams were prepared “to remove each inmate from their respective cell,
to search, remove contraband[] and return each inmate to their cell.” NJDOC
documentation states that the Associate Administrator along with two majors at the facility
-31-
2. Contact with NJDOC Central Office
That same night, Associate Administrator St. Paul made contact with NJDOC
Central Office to report that an inmate disturbance had taken place on the RHU.
REDACTED
REDACTED
-32-
REDACTED
Deputy Commissioner Ricci did not make contact with Commissioner Hicks that
night about her dialogue with St. Paul. The timing of Commissioner Hicks becoming
aware of the cell extractions and the content of what he was told are discussed later in this
report. EMCF’s SID unit was not notified that the cell extractions were to take place, nor
was the OCO notified. Ombudsman DiBenedetti stated to us that in the past “the DOC has
notified me occasionally of searches and I have staff and/or myself report to the facility to
observe the event and complete a report a containing our observations.” That notification
The January 11 cell extractions in the RHU (the “Cell Extractions”) began at
approximately 10:30 p.m., 30 minutes into EMCF’s third staffing shift. According to
NJDOC records, 22 inmates in total were taken out of their cells. Seventeen inmates left
their cells without incident, four inmates required a forced extraction, and one inmate
initially complied but later became non-compliant. Records further indicate that no
contraband was discovered during the course of the extractions and related searches.
Lowenstein reviewed the videos that officers recorded of the Cell Extractions, as
well as recordings from the cameras mounted on the walls in the RHU. The videos show
that the Cell Extractions were conducted by groups of five officers, each of which was led
-33-
by a sergeant (“Extraction Teams”). The officers wore riot gear and carried shields and
canisters of pepper spray. Both male and female officers were involved in the Cell
Extractions.
According to NJDOC records, there were two Extraction Teams. Two sergeants
were assigned to videotape the extractions, with one sergeant being assigned to each team.
Additional officers escorted the inmates once they were removed from their cells.
According to NJDOC records, 37 officers put in overtime due to the Cell Extractions during
During each of the Cell Extractions, the five officers on the Extraction Team lined
up in the hallway outside the inmate’s cell while the sergeant asked the inmate to put her
hands out through the food port to be handcuffed. Some inmates complied, while others
did not. The five officers then rushed into the cell, handcuffed the inmate (if not already
cuffed), put leg irons on her, and brought the inmate out of the cell. The lead sergeant
typically entered the cell, as did the video recorder, meaning that there were a total of seven
custody staff in each cell during the extractions. After being removed from the cell, each
inmate was escorted to the Medical Office for assessment, to a shower if she had been
moment because the recording officer is standing behind other officers, frequently
recording the officers’ backs instead of recording the inmate and what is happening to her.
While the officers are supposed to be identified by name before cell extractions are
-34-
conducted, this did not occur on the videos described below. Additionally, certain events
Below is a summary of each of the forced Cell Extractions based on the video
recordings. The videos are exceedingly violent and are alarming in a way that is difficult
to put into words. One senior NJDOC official we interviewed described the video footage
i. Extraction 1
The video of Inmate 1’s cell extraction begins with a sergeant ordering her to put
her hands through the food port to be handcuffed. She complies with the order. Her
cellmate, Inmate 5, was removed from the cell (described in further detail below), and then
the camera returned to the cell, where officers tell Inmate 1 to “stop resisting,” but she is
not visible as officers are blocking the view into the cell. Inmate 1 is pushed out of the cell
by the Extraction Team, with one officer pulling her by her sweatshirt.
Inmate 1 is held against a wall in the hallway for several minutes. She protests,
“I’m somebody!” The Extraction Team then takes her into the Medical Office for an
assessment. She says she does not want any medicine. The sergeant deems Inmate 1 to be
refusing a medical assessment, though she says she is not. The Extraction Team takes her
out of that office and the sergeant says to take her to the “strip cell.”
Inmate 1 is then taken into an empty cell with tiled walls identified in reports as the
South Hall North Wing shower area or the South Hall North Wing strip room. There are
seven officers behind her, and they ask her to strip, which she refuses to do. The male
officers leave, and three female officers enter the cell. Inmate 1 says at one point, “It’s in
-35-
my pussy and y’all ain’t getting it.” The officers begin forcefully cutting her clothes off.
The officers pull at the clothes and use a hooked blade to attempt to cut through them. Her
sweatshirt is torn, but her clothes are not removed. During some of this period, the camera
is pointed up or towards the wall. Inmate 1 begins spitting at the officers. The camera is
then pointed towards the wall while there is some commotion so it is unclear what happens,
but Inmate 1 is then on the ground with officers surrounding her, including male officers.
She repeatedly says “get off of me” and at one point says “get off my titty.”
Inmate 1 is then carried out of the strip cell while the officers say they are going to
put her in another cell and strip her. She is put into a cell, but it is not possible to see her
on the video as there are four or five officers crowding around her, including male officers,
who remain in the cell during the forced strip search. Inmate 1 says that the officers are
mad they got “splashed.” She says that she is going to make the officers’ lives as difficult
as possible and that she is about to bite one of them. A male officer again tells her to “stop
resisting.” One of the officers hands a sharp object to another. Some type of struggle
seems to take place, but cannot be seen on the video as there are officers blocking the
camera view. Inmate 1 asks, “Why is it a man ripping my clothes off? Why is you grabbing
my titties?” Some of her clothes are then thrown out of the cell. She yells, “PREA!” The
officers leave the cell and Inmate 1 is naked, apparently left in the cell alone, and the video
ends.
According to Inmate 1’s subsequent written statement, she complied with the order
to be handcuffed, and the officers then entered her cell and “kicked, punched, slammed,
and grabbed [her] hair.” She stated that the officers bent her arm back, cracking it out of
-36-
place. She wrote that she was taken to the shower where the officers “began to rip [her]
clothes off” with a “sharp knife like object,” which was not working. She stated that the
officers then took her to cell number five, where both male and female officers assaulted
her. She wrote that her shirt was ripped off, and that one officer choked her, grabbed her
breast, and “put his hands in [her] vagina,” scratching it and causing it to bleed.
The reports filed by the sergeant who supervised the Extraction Team and the
sergeant who videotaped the extraction state that Inmate 1 refused orders to strip, became
aggressive and started spitting at the officers. The reports incorrectly state that female staff
entered the area to forcibly remove Inmate 1’s clothing, while she continued to be non-
compliant.
The reports describe that Inmate 1 was later found lying unresponsive on the floor,
about an hour after the extraction, so a team of suited officers entered the cell and placed
her in a wheelchair. When she regained consciousness, she allegedly became belligerent
and non-responsive, and began spitting at the officers. According to the reports, Inmate 1
refused a medical assessment and was taken to the infirmary. There is no evidence of these
events on video.
Reports filed by the two sergeants state that Inmate 1 sustained no injuries during
the Cell Extraction. However, a medical report from January 12 notes she had superficial
scratches and visible purple bruising on her hand. Notes from the nurse at EMCF state it
was later determined that she broke her arm and that she received a cast.
-37-
ii. Extraction 2
The video of Inmate 2’s cell extraction begins with a sergeant ordering her to put
her hands through the food port to be handcuffed. She says, “I’m not going” and that she
needs to use the restroom. The sergeant sprays pepper spray through the food port and
immediately (contrary to NJDOC policy) opens the cell door. The Extraction Team rushes
into the cell. Inmate 2 is pushed against the wall and the officers repeatedly tell her to
“stop resisting.” An officer pulls her back by her braids while another officer punches her
numerous times on her face, chest and back. It is difficult to see what is happening due to
numerous officers being inside the cell, but the sound of punches landing is audible and
goes on uninterrupted for about a minute. Inmate 2 has her arms up, attempting to cover
her face, while she is pressed against a wall with her back to the officers. She says, “Stop
punching me in my face.” Charges subsequently filed by the New Jersey Attorney General
allege that one officer alone punched Inmate 2 in the head and neck 28 times.
Ultimately, the officers push Inmate 2 out of the cell and she has a visibly bloody
mouth and squinting eyes. Her shirt is open. The officers hold Inmate 2 against a door.
An officer tells her to listen to orders and stop resisting; she says she is listening to orders
and is not resisting. She asks to be covered up. The officers walk her through the hallway
and as they walk, an officer yells at her, “You’re going to listen to my orders, do you
understand? If you don’t listen to my orders, you will get sprayed again. Do you
understand?” She does not respond. As she is brought into the Medical Office, she says,
“Y’all got my chest out, in front of the audience.” Her shirt is still open.
-38-
Inmate 2 tells the nurse that the officers punched her in her face and chest and that
she has a concussion. The officers tell her they are going to strip search her. Inmate 2 asks
if the nurse can wipe her face as it is burning. The nurse says she is not sure if she has any
bandages. The officers take her to a shower and tell her to put her face in the water. She
says that she does not want to get in the shower. An officer then says “strip cell” and points
to a cell. The officers walk her down the hallway, but then take her back to the shower to
strip. Inmate 2 faces the camera and says, “Y’all see my lip on this camera? I’m about to
The officers lock Inmate 2 in the shower for her to strip (the door is grated but has
a curtain in front of it). She says, “Y’all want to beat the life out of me.” A male officer
tells her to strip and put her pants through the porthole. She says, “Please back up, I don’t
have no clothes on. This is PREA.” She gives her pants and underwear to a female officer
through the porthole, but male officers remain present. The female officer tells her to turn
around, squat and cough. After some back and forth, Inmate 2 says she is not doing that.
An officer tells her she will be sprayed again if she does not comply. The female officer
attempts to talk to Inmate 2 again, but she still does not comply with the order. A male
officer says, “At this time [Inmate 2] is not complying,” and pepper sprays her through the
grated door. She turns on the shower, presumably to wash off the pepper spray. The officer
tells her to put her hands through the porthole to be handcuffed. Inmate 2 continues to
shower while he repeats his orders. Inmate 2 says that she will strip and turns around and
coughs. She asks for clothes, and the officers give her clothes through the porthole. They
-39-
then cuff her through the porthole and walk her down the hallway to the cafeteria where
The sergeant’s special custody report states that Inmate 2 refused his orders to be
placed in handcuffs and that he then deployed pepper spray. The report then incorrectly
states, “[Inmate 2] continued to refuse all orders to be handcuffed. [The sergeant] then
ordered his team to enter the cell.” The video footage, however, shows that Inmate 2 was
not given an opportunity to comply with the handcuff order after the pepper spray was
Another officer’s report states that after entering Inmate 2’s cell, “she was throwing
punches towards [his] torso area” and that he “used physical force to gain compliance.”
The video recording does not show the inmate punching the officer.
The use-of-force reports from the on-site sergeants both state that Inmate 2 sustained
no injuries during the Cell Extraction. The on-site medical report from that night, however,
states that she had a bleeding lower lip, which is visible on the video footage. The next
day, she was assessed by a nurse at EMCF, who noted that she had a swollen red/purple
lower lip with a small cut inside, bruises on her eye, arm, and shoulder, and a cut on her
right hand. Inmate 2 was taken to a hospital that day and was found to have suffered a
iii. Extraction 3
Contrary to NJDOC policy, Inmate 3’s cell extraction was not recorded at all. There
is video footage following her extraction, which shows her with a black eye and bloody
face. The officers walk her through the hallways to the Medical Office and she says, “They
-40-
punchin’ me all in my eye for no reason. . . . I ain’t even do nothing. Stop hurting me.
Why are they punching me in my eye.” She tells the nurse she has a bad headache and
cannot see. She starts crying and says she did not do anything wrong and is hurt. The
officers take her out of the office and she repeatedly says, “Stop hurting me,” while crying.
There is blood on her face, which seems to be coming from her eye. The officers walk her
down a hallway, outside and to another building where they bring her into a cell. Her black
eye and blood on her face are visible. Twice she says to the officers that they should be
more focused on the inmates who are actually squirting them, as opposed to her. A nurse
comes in to see her and says she is going to come back with a blood pressure monitor, but
does not return. The officers take Inmate 3 to a cell for a strip search and take off her
handcuffs. The officers all leave the cell, and she removes her clothes and gives them to
two female officers through the porthole (no male officers appear to be in the hallway).
One sergeant’s report says that he filmed Inmate 3 and that she “became self-
injurious.” The Attorney General’s criminal charges state that this report was false.
Similarly, another officer’s report seems, falsely, to try to explain her injuries by saying
that she was “banging her head on the cell door.” The criminal charges state that video
shows Inmate 3 did appear to throw an unknown white liquid out of her cell into the
hallway, but further that during her cell extraction she immediately complied with an order
to be handcuffed before officers entered her cell. The related affidavits say that, according
to other inmates, Inmate 3 “begged officers not to harm her” and that she was “crying in
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pain” as corrections offers struck her multiple times with their fists, despite her being
The medical reports from the night of the Cell Extractions state that Inmate 3’s right
eye was completely swollen shut and that her mouth was bloody. On January 12, she was
taken to a hospital and was found to have suffered an orbital wall fracture.
iv. Extraction 4
The video recording of Inmate 4’s cell extraction shows a sergeant ordering her to
“cuff up” through the food port. She does not comply with the order. The sergeant repeats
his order. After 30 seconds, the sergeant sprays pepper spray through the food port. He
again asks her to “cuff up” and tells her to “stop grabbing that, we’re coming in.” The
Extraction Team then rushes into the cell. Inmate 4 is not visible as the officers are in the
way of the camera and the lights in the cell appear to be off. The officers repeatedly tell
her to “stop resisting” and she seems to be on the floor. One of the officers says to “pull
her pants up.” As the Extraction Team then takes her out of her cell, her pants are falling
down her legs. The officers take her to the Medical Office, and she says she has no injuries
or bruises. She is put into a cell to strip, and the male officers leave while three female
officers remain outside and monitor the strip search, which takes place without incident.
The sergeant’s ensuing report states that Inmate 4 refused to report to the food port
to be handcuffed, so he deployed pepper spray. His report also claims that he “observed
her reaching under her bed for a possible weapon” prior to the Extraction Team entering
the cell. We were not able to substantiate that claim through the video evidence.
-42-
v. Extraction 5
The video of Inmate 5’s cell extraction shows her complying with the sergeant’s
order to put her hands through the food port to be handcuffed. The Extraction Team then
rushes into her cell. She is not visible on the video at this point, but seems to be on her bed
with the officers crowded around her. The officers yell at her to “stop resisting,” and she
says she is not resisting. A struggle can be heard for about a minute. The Extraction Team
then drags her out of the cell, with officers holding her legs and another officer holding her
arms. The officers push her down the hallway. She is then laying on the floor with officers
surrounding her. The officers tell her to “stop resisting,” and she says she is not resisting.
There is no further video of Inmate 5. The camera then turns to Inmate 1 who is
NJDOC records reveal that some of the officers participating in the Cell Extractions
For example, disciplinary records indicate that one of the lieutenants suspended
following the Cell Extractions has been disciplined twice previously for failing to properly
record a cell extraction or escort. In 2013, the lieutenant received an official reprimand
after he “operated the camera in the still photo mode, rather than the video mode[,]
[t]hereby rendering the taping useless.” Then, in 2016, he was suspended after he was
shown on “surveillance video holding [his] assigned video camera down to [his] side while
-43-
Similarly, NJDOC records indicate that another one of the officers involved in the
Cell Extractions had been disciplined previously for failing to conduct a cell search in a
Two supervisors involved in the Cell Extractions were alleged to have engaged in
violent conduct while off-duty during their employment with NJDOC. Senior NJDOC
the Cell Extractions was arrested in 2017 for criminal mischief after he allegedly punched
a door during a domestic violence incident with the mother of his child, who also was an
EMCF correctional officer at the time. He was placed on a “no armed post” list, until the
criminal mischief charge was dismissed in 2018 and he underwent an evaluation that
deemed him fit to possess a weapon. He later became romantically involved with another
EMCF employee, allegedly leading to a “love triangle” that resulted in one of the women
Records show that another senior EMCF official self-reported being involved in two
separate incidents in which he discharged his off-duty firearm while driving. In the second
incident, which was reported in 2003, he allegedly shot at another driver. The EMCF
official stated that the other driver had a gun pointed at him and refused to lower it, but
witnesses said the other driver was unarmed and that the official shot at him as he drove
away. This same EMCF official was one of the individuals who last year formally
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D. The Response to the Cell Extraction Incident
charges against Inmate 4 for splashing officers with an unknown liquid and Inmates 1 and
3 for spraying unknown liquids and attempting to hit officers. As noted above, the physical
evidence against Inmate 4 included a bottle of hair conditioner “with an inmate pen
hollowed out attached to bottle.” The charge against Inmate 3 was later changed to “being
Through the NJDOC adjudication process, all five inmates initially received
sanctions based on the above charges. Sanctions against Inmates 3 and 5 were upheld on
appeal, with the explanation for Inmate 5 stating, “Reports indicate you were non-
compliant throughout the search . . . . Start focusing on your actions since you will be held
“leniency.” Most of Inmate 4’s sanctions were suspended on appeal, but a 30-day loss of
phone privileges and 30-day loss of JPAY and email were upheld.
When Commissioner Hicks became aware of these charges, he directed that they be
suspended. All proceedings regarding them are currently on hold, and the discipline has
not been carried out. The process through which NJDOC Central Office learned of the
NJDOC senior officials were first notified of the Cell Extractions via an email from
the NJDOC Central Operations Desk (“COD”). At each NJDOC facility on each shift,
there is a shift commander responsible for reporting to COD any qualifying incident that
-45-
occurs during that shift. COD sends periodic emails to a large list of recipients, including
NJDOC officials and facility supervisors, which contain reports of major incidents across
NJDOC facilities.
On January 12, 2021, at 4:17 a.m., COD sent such an email, stating that at 11:30
p.m. on January 11, St. Paul and two others on site gave the order to have all RHU inmates
removed from their cells and strip searched, and for cell searches to be conducted as well.
The email stated that all but four inmates complied and that no injuries were reported.
Later that morning, Inmate 2 called the OCO to lodge a complaint regarding the
Cell Extractions. The OCO’s notes of that call indicate that Inmate 2 alleged she was
punched in the face and suffered a concussion and an injured lip. Ombudsman DiBenedetti
emailed SID and EMCF staff regarding Inmate 2’s allegations. SID Chief Grade then
forwarded that email to the EMCF SID Principal Investigator for investigation, noting that
the COD report had stated that there were no injuries during the Cell Extractions. Grade
asked the investigator to ensure that Inmate 2 had been medically evaluated.
Around noon on January 12, Inmate 2’s aunt called NJDOC Central Office staff
regarding the Cell Extractions, stating that Inmate 2 had been part of an “assault” at EMCF.
She said that one of the other inmates had been rushed to the hospital “with her eye knocked
out of the socket.” Ricci emailed that information to Grade, copying Hicks, asking that it
be investigated. Ricci noted that she was not previously aware of any inmate going to the
hospital.
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At 5:45 p.m. on January 12, Ricci emailed Hicks directly, copying Grade, noting
that
REDACTED
Ricci said,
“This is a real concern.” Hicks stated during his interview with us that he first became
Investigator asked one of her investigators to review the video footage from the handheld
cameras used during the Cell Extractions. Upon reviewing a portion of the footage, the
investigator told her, “I think we have a problem,” which the Principal Investigator relayed
to Grade. That led to the entirety of the video footage being secured for further review.
On January 13, the EMCF SID unit obtained and reviewed the video coverage. They
then spoke to Grade about it, who advised them to inform law enforcement, which they
did.
At 11:44 a.m. that day, the NJDOC Managing Physician emailed Ricci about Inmate
3. He noted his “concern” about the use of pepper spray on a patient with a history of
asthma. He also noted that the initial nurse documented redness in Inmate 3’s eyes
following the use of pepper spray, but the next shift nurse noted a completely closed eye
with bruising. Ricci responded, copying Hicks and Grade, asking for additional details.
At 2:50 p.m., Ricci emailed the incident reports to Hicks. She again noted that
REDACTED
nor were the injuries in the
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COD report. She requested that St. Paul be temporarily reassigned pending an
investigation and that Patricia McGill be moved to EMCF as Acting Administrator. Hicks
responded and approved the recommendations. He stated in his interview with us that after
learning there were injuries, the first thing he wanted to know was whether the inmates had
been medically assessed and received appropriate medical treatment. He said his second
priority was to find out what was on camera and how quickly the footage could be
produced.
On January 14, there were multiple outreaches to the OCO by, or on behalf of,
inmates involved in the Cell Extractions. First, Inmate 1’s sister contacted the OCO
alleging that one of the officers had ripped off her sister’s clothes, groped her and placed
his fingers in her vaginal area. The OCO provided that information to Grade and to the
EMCF PREA compliance unit. The PREA Compliance Coordinator responded that she
had initiated PREA protocols, which included moving Inmate 1 to a protective custody unit
until SID could interview her. Second, Inmate 3 called OCO. She alleged that she had
been physically assaulted and punched in the face. DiBenedetti emailed that information
to Grade and others in SID, copying Ricci. Grade responded that the matter was under
investigation by SID. Third, Inmate 4 called OCO and made similar allegations.
DiBenedetti personally spoke with Inmate 4 when she called, and he advised her that SID
would be speaking with her. DiBenedetti then emailed Central Office SID and EMCF SID
Also on January 14, EMCF SID delivered the video footage of the Cell Extractions
to Central Office SID. Grade viewed the footage later that day.
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The next morning, January 15, Grade reviewed the video footage with Hicks, Ricci
and other Central Office staff. (Hicks and his staff had obtained the video footage on
January 14, but because of technical difficulties, Hicks initially was not able to review the
footage.) When Hicks saw the videos, he decided to suspend the individuals involved,
pending further investigation. During his interview with us, Hicks said he was disgusted
On Saturday afternoon, January 16, Hicks emailed senior officials at the Governor’s
Office informing them that the EMCF Associate Administrator had authorized four cell
extractions on January 11. He stated that at least two inmates suffered injuries, specifically,
“1 inmate suffered a broken arm and another suffered facial injuries.” Hicks further stated
that he placed 29 staff on leave pending an SID investigation for violation of policies and
potential use of excessive force, and that the Hunterdon County Prosecutor’s Office had
been contacted to review the incident for potential criminal prosecution. Hicks stated that
the Cell Extractions had not been authorized by anyone in NJDOC except the Associate
Administrator.
During his interview, Hicks told us that this method of communication is typical for
his dialogue with the Governor’s Office. He does not reach out directly to the Governor;
if an emergent issue arises, he will reach out to the Governor’s chief of staff or chief counsel
by email or phone.
Seven minutes after Hicks’ email, the Governor’s chief counsel responded, asking
if the Attorney General’s office had been notified. Hicks confirmed that they had,
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specifically, a referral had been made to criminal authorities at the Office of Public
In his interview with us, the Governor said that upon being briefed, he was
disgusted, deeply concerned and upset. He said that in response, separate from having
guilty parties brought to justice through the criminal process, he directed this outside
investigation to take place to determine what had happened and how it happened, and to
A. Conclusions
In addition to the findings noted above, the following are conclusions regarding the
As noted above, third-shift cell extractions are reserved for emergency situations,
because there generally are not enough staff members during third shift to respond
appropriately if a situation becomes volatile. As a result, both the current and former
EMCF Administrators told us that had they been asked to authorize these third-shift Cell
Administrator McGill said that from what she knew about the incident, there was
“no pressing need” to remove contraband from inmates’ cells. Former Administrator Davis
likewise said she would not have considered splashing to be an emergency justifying cell
extractions, particularly on third shift. She noted that she has witnessed riots during third
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shift that were not determined to require cell extractions. Davis conveyed a sense of guilt
about the Cell Extractions and her absence from the facility, stating, “God knows this . . .
would not have happened” had she been present. Another EMCF supervisor similarly said
that she would have waited until first shift to conduct cell searches in response to splashing
incidents, because inmates are often out of their cells for recreational time during first shift,
The lapse in time, including a shift change, between the last splashing incident
around 8:30 p.m. and the first cell extraction at approximately 10:30 p.m., indicates the
absence of a true emergency justifying a third-shift cell extraction. In the absence of a true
emergency, the motives underlying the conduct here become more apparent. As opposed
to an attempt to quell a legitimate emergency, the Cell Extractions were a misguided effort
by frustrated employees to restore order and mete out discipline in response to splashing
As explained above, NJDOC policy states that once a cell extraction is approved, it
cannot proceed until “a custody supervisor with a video camera” arrives. The policy
provides specific tasks that must be completed on camera prior to the cell extraction, none
of which were present on the recordings described above. First, the supervisor recording
the cell extraction is to announce the date and time that the recording is beginning, his or
her name and title, the location of the recording, the reason for it, the name of the
correctional facility, and the name and identification number of the inmate(s) involved.
The video recordings did not include this required statement. Next, the custody supervisor
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overseeing the extractions must provide an on-camera briefing, including the names and
responsibilities of all team members, and provide instructions for and describe the purpose
of the extractions. The team members themselves must announce their name, team number
and specific responsibility on camera. This announcement did not occur on video
recordings described above, and Commissioner Hicks noted the same in our interview of
him.
Once the pre-extraction briefings are complete, the entire incident must be recorded,
and the recording must not stop until after the inmate has been examined by medical staff.
Nonetheless, video recordings of the Cell Extractions were frequently filmed in such a way
that it was impossible to see what was happening to the inmate. Instead, the camera was
frequently positioned behind members of the Extraction Team, filming their backs instead
of filming the inmate involved, or filming a wall. For instance, the recording of Inmate 2’s
cell extraction does not depict Inmate 2 while an officer audibly punches her for about a
minute straight.
In addition, our investigation found that some Cell Extractions, or portions thereof,
were not recorded at all. For example, Inmate 3’s cell extraction, which resulted in her
suffering a skull fracture, was not recorded. The video footage of Inmate 3 shows her
already injured, with a visible, swollen black eye and bloody face, as she is transported to
the Medical Office. There is no video footage supporting officers’ claims in incident
reports that Inmate 3’s injuries were a result of her becoming “self-injurious” or “banging
her head on the door.” Likewise, there is no video supporting officers’ claims in incident
reports that Inmate 1 was discovered “unresponsive” in her cell and “became belligerent”
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toward officers when she regained consciousness. Nor is there video footage that explains
Commissioner Hicks told us that in his opinion, the inadequate filming was
intentional. He said “there were instances where the camera was pointed at the floor, or it
wasn’t even on . . . . I don’t think that was coincidental. And it was completely inconsistent
with what our policies are.” We were similarly told by a former NJDOC official that
improperly filming cell extractions and telling non-resistant inmates to “stop resisting” are
use of force.
NJDOC policies and State regulations related to the use of force emphasize that any
use of force by correctional officers must be “objectively reasonable” and that custody staff
must exercise “the utmost restraint” when using force. Additionally, the policy governing
forced cell moves states that inmates must be provided “a reasonable amount of time to
comply” with orders before force is used, so long as there is “no immediate danger to the
Custody staff failed to follow protocols related to use of force and used excessive
force during the Cell Extractions. First, pepper spray was used inappropriately during the
Cell Extractions. The use of pepper spray qualifies as a use of force pursuant to NJDOC
cell extraction policy. The policy states that once pepper spray is deployed against a
noncompliant inmate, the extraction team should wait “approximately two (2) minutes”
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and then give the inmate another opportunity to comply with the instruction before
beginning the extraction. In contrast, video recordings of Inmate 2 and Inmate 4 show
custody staff deploying pepper spray and then immediately entering the inmate’s cell,
officers should have given the pepper spray time to take effect such that the inmate could
Second, we found that in at least three of the Cell Extractions, custody staff
employed a level of force that could not be considered “objectively reasonable.” Video
recordings showed an officer holding Inmate 2 by her hair while another officer repeatedly
punches her on the face, chest and back. She never appears to be resisting, but rather
appears to be attempting to cover her face to avoid being punched. Inmate 2 received
external medical attention and was ultimately diagnosed with a cervical sprain and a
concussion. Further, before Inmate 1 was strip searched, custody staff are visible on video
ripping her clothes in what appears to be an unnecessarily violent manner. Moreover, there
is no video footage showing how Inmate 3 sustained a skull fracture, nor how Inmate 1
sustained a broken arm. While we will leave assigning culpability among specific
individuals present that night to criminal prosecutors, overall conclusions regarding the
All of this taking place during an ongoing federal probe at EMCF, and after a critical
DOJ report, renders the conduct all the more jarring. Phrases used by NJDOC officials
describing their reactions included “blows my mind,” “shocking,” “beyond frustrating” and
“devastating.”
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4. Custody Staff Filed False Reports
NJDOC policy requires immediate reporting of use of force by “each staff member
who participated in or witnessed the event,” by way of a special custody report. The
“ranking custody staff member on the scene” must also complete and submit a “use of
force” report. The reports must include, among other facts, a description of the type of
force used, the reasons for employing the force and a description of any injuries sustained.
Our investigation revealed that custody staff filed false reports regarding several of
the Cell Extractions. For example, incident reports describing Inmate 1’s cell extraction
state: (i) female officers strip-searched Inmate 1; (ii) Inmate 1 was later found unresponsive
in her cell, then regained consciousness and became belligerent; and (iii) Inmate 1
sustained no injuries during the extraction. However, (i) male officers are visible inside
the cell while Inmate 1 is strip searched and appear to have participated in the search; (ii)
there is no video evidence suggesting Inmate 1 was at any point unresponsive; and (iii)
Incident reports describing Inmate 2’s cell extraction state that she: (i) refused
orders to be handcuffed; (ii) was “throwing punches” toward custody staff; and (iii)
sustained no injuries. In contrast, video recordings and medical reports we reviewed show
that: (i) Inmate 2 was not given an opportunity to comply after pepper spray was deployed;
(ii) Inmate 2 was neither resistant nor violent; and (iii) Inmate 2 sustained a swollen lip,
bruises on her eye, arm, and shoulder, a cut on her right hand, a concussion, and a cervical
sprain.
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Reports describing another inmate state that she became “self-injurious” and was
“banging her head on the cell door.” Thus, the reports would indicate that the injury
officials, delaying their awareness of the fact that inmates had been seriously injured. For
example, a COD report circulated at 4:17 a.m. on January 12 states that no injuries were
reported following any of the Cell Extractions and it does not even list Inmate 3 as one of
the inmates removed from her cell. Even a “corrective late report” circulated by COD
more than twelve hours later, at 7:54 p.m. on January 12, states that no injuries were
NJDOC policy provides that strip searches of inmates must be conducted by staff
of the same gender outside of emergency circumstances. It also states that searches must
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said that because cell extractions typically include strip searches, it is “preferable” for
interviewed said that it was acceptable for males to be on extraction teams as long as they
strip searches, NJDOC officials and EMCF supervisors we interviewed generally felt that
the Cell Extractions were not conducted in circumstances that were emergent.
Nevertheless, video recordings of Inmate 1’s cell extraction show that male officers are
inside the cell while she is strip searched, and suggest that at least one male officer actively
engaged in the search, and potentially conducted a body cavity search. While the camera
is blocked by other officers as Inmate 1’s clothes are removed, she is heard asking, “Why
is it a man ripping my clothes off?” According to Inmate 1’s written statement, a male
officer also digitally penetrated her in the course of the strip search and caused vaginal
bleeding. Custody staff also failed to report this cross-gender strip search, contrary to
NJDOC policy. As noted in the previous section, incident reports falsely stated that only
female officers participated. In addition, this search certainly was not conducted in a
“professional and respectful manner”; custody staff are seen on video tugging at her
clothes, struggling to rip them off of her, and moving her between multiple cells in the
process. Male officers also were present for Inmate 2’s strip search.
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6. Unclear and Informal Authorization Protocols Likely
Contributed to the Occurrence of the Cell Extractions
extractions, both in general and specifically on the facility’s third shift. NJDOC officials
told us that NJDOC Central Office issued a directive to all facility administrators last year
that Central Office approval is required to conduct cell extractions on the third shift. We
requested from NJDOC documentation reflecting that directive and were informed that it
was not communicated in writing. NJDOC policies were not updated to reflect the intended
The cell extraction authorization protocols that are set forth in written policy appear
to be inconsistent. In a span of three pages, the existing policy states that: (i) “[t]he decision
to force an inmate to move is made by senior custody supervisors in conjunction with the
facility Major and Administrator”; (ii) a forced cell extraction cannot proceed “without the
approval of the Administrator or On Call designee”; and (iii) a use of force may be
authorized by any “custody staff member with the rank of sergeant or above.” The policy
thus spells out three different protocols that all may apply to the same occurrence, which
makes the required authorization unclear. Seemingly in contrast to the policy, in his April
8, 2021 testimony before New Jersey Assembly committees, Commissioner Hicks stated
that “there has to be Central Office notification before a cell extraction takes place.”
fully clear on when, if ever, Central Office authorization is required to conduct cell
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extractions. Sarah Davis said she did not typically seek approval from Deputy
Commissioner Ricci to conduct cell extractions because the need to conduct an extraction
generally results from an “urgent situation.” She said when she did speak to Ricci about
a cell extraction, she would call Ricci saying, “this is what we’re planning to do,” as
Central Office, and said that on the third shift specifically she would not authorize staff to
open any inmate’s cell door “without authorization” from Central Office. She said that in
true emergency (e.g., life or death, attempted suicide) situations, however, Central Office
Our investigation determined that the lack of a formal directive or policy stating that
Central Office must approve a third-shift cell extraction contributed to what happened on
January 11. While the available evidence indicates that Central Office generally had
denied permission to conduct third-shift cell extractions when asked in the past, there is
nothing in writing stating that such consultation had to take place. Nor are there any
records formally memorializing whether St. Paul sought Deputy Commissioner Ricci’s
approval here, or whether she granted it. Nor is there any evidence that Commissioner
Hicks was informed of any aspect of this highly volatile situation as it was developing or
before the Cell Extractions were carried out. Had NJDOC policy explicitly stated that
memorialized Central Office approval was required to conduct third-shift cell extractions,
we believe it would have been denied here, thereby avoiding all that followed.
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7. Conducting Unit-Wide Cell Extractions Made for an Even More
Disruptive and Volatile Situation
highly unusual to conduct cell extractions across an entire housing unit. Administrator
McGill told us that she has never seen a situation where multiple cell extractions were
authorized and conducted simultaneously. Commissioner Hicks likewise stated that unit-
wide searches generally do not occur unless NJDOC has “evidence or intelligence that the
The Cell Extractions appear to qualify as a “mass search,” which NJDOC policy
documents state “may be authorized due to specific information received from a third party
light of the staff member’s experience or knowledge of inmates.” In this instance, however,
none of the incident reports indicate that the entire unit was likely or even believed to
possess contraband. Instead, the reports indicate that three inmates at most attempted to
from their cells. Expert consultants we spoke with said the fact that officers removed all
RHU inmates from their cells shows that “what the officers were trying to do [was] send a
As detailed in Part III.C of this report, NJDOC and EMCF have worked to
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conditions at EMCF. However, our investigation found that delays in implementing some
remedial measures contributed to the occurrence and violence of the Cell Extractions.
For example, NJDOC has been working to implement an Early Warning System
(“EWS”) since 2018. The EWS is a comprehensive digital system that receives
information from various divisions within NJDOC and alerts NJDOC Central Office when
attendance concerns, litigation alerts or other issues. Central Office is to review each alert
and determine what action, if any, to take, ranging from an investigation of the officer to
provision of counseling. As to the lapse in time between initial efforts in 2018 and recent
completion of the EWS in 2021, Commissioner Hicks said that the delay was partially due
to the need to aggregate information from various internal databases, upgrade related
systems, and develop EWS policies and procedures. He said that once Covid-19 became
an issue, resources that otherwise would have been allocated to EWS implementation were
Hicks in May 2020, he stated that the EWS would be operational by June 30, 2020.
Ultimately, however, it reportedly went live on April 1, 2021. Commissioner Hicks told
us that there is no doubt that if EWS had been operational before January 2021, it would
have flagged for further review some of the officers who were involved in the Cell
Extractions.
program, and in May of this year the cameras began to be used at the facility, with 120
BWCs now in use there. According to draft NJDOC policies we reviewed, correctional
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officers will utilize BWCs primarily “for the purpose of recording incidents, searches, and
encounters” including cell extractions and any use-of-force incidents, among other
occurrences. Half of the funding for the program was secured in 2018 through a grant from
the federal Bureau of Justice Assistance. Commissioner Hicks said that the three-year
lapse in time between receipt of the grant and the program’s implementation was due to an
issue with the original vendor’s bandwidth connectivity, which became apparent only in
December 2020. At that point, another vendor took over. No officers at EMCF were
outfitted with body cameras as of January 11. One of the issues we identified above –
custody staff’s failure to properly video record the Cell Extractions – likely would not have
occurred if officers were wearing BWCs when the extractions were conducted. Indeed, we
question whether, in that scenario, the Cell Extractions would have occurred at all.
B. Recommendations
It is clear that significant changes are necessary to break the current cycle of
misconduct at EMCF. The sexual abuses discussed in the April 2020 DOJ findings letter
occurred secretly and in hiding. In contrast, the conduct associated with the Cell
Extractions happened in the open, in the presence of numerous people and multiple video
cameras, revealing the significance of the challenges that remain at the facility.
agreement with DOJ, which NJDOC expects will include numerous specific requirements
for EMCF to fulfill, in addition to the naming of a federal monitor. Consistent with our
charge, we leave those new requirements for discussion elsewhere and focus our
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1. Independent Oversight
The Ombudsperson stated in his interview with us that although his office is
available to participate in “special assignments” such as cell extractions, EMCF has never
called upon his office to participate and he and his staff have never sought to do so. He
agreed with us that having someone from OCO or an entity such as SID present to observe
note that during the course of our investigation, NJDOC directed that, going forward, a
SID investigator would be responsible for filming cell extractions at all NJDOC facilities.
More generally, a strong and independent SID is vital to the health of EMCF as a
facility. Currently, all SID investigators are themselves former correctional officers,
potentially having attended training at the Academy or even worked alongside the officers
whose conduct they now investigate. That may impact the impartiality, or at least the
While we recognize that SID has made efforts to remain independent and at arms’
length from correctional officers, recent events counsel in favor of revisiting the current
approach. Consideration should be given to having at least some SID investigators who
do not come from the ranks of correctional officers. As a former EMCF official stated to
us, other law enforcement perspectives and backgrounds would be valuable to SID, or at
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least further inmates’ confidence in the impartiality of the process. We note that the current
SID chief is retiring at the end of this year, which provides an opportunity for a fresh start
and an examination of the unit. New ideas such as having, for example, an entity such as
the State Police involved in the work of SID, at least in the near term, should be explored.
Along similar lines, recent legislative amendments contemplated that the OCO,
which is now empowered with subpoena authority and a litany of other tools, would
become an aggressive and proactive actor in ensuring that inmate rights are respected.
Nonetheless, our investigation revealed that in the time leading up to the Cell Extractions,
OCO largely had become, in effect, an office that receives complaints and then simply
refers them to another party to resolve them. As one inmate reported in her interview, the
OCO “is invisible to us.” The publicly announced upcoming retirement of the
proactive in its involvement at EMCF specifically and focus more of its resources on that
facility.
Independent oversight of cell extractions will help, but it is important that those
overseers, and those whose conduct they are reviewing, have an awareness of the rules that
need to be enforced. The policies and procedures for cell extractions must be in writing
and clearly communicated to staff both during initial training and at regular intervals.
Those procedures should include protocols for seeking authorization to conduct cell
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extractions. The approvals themselves in each instance should be memorialized in some
form, such as via e-mail. Greater personal accountability and related internal controls are
Getting the right people to carry out cell extractions and similar measures is also
was a “crucial need for more Gender Restricted Posts,” meaning, more female staff at the
hurdles, progress has been made since that time. Records indicate that currently, a total of
55 posts (split among three work shifts) are gender-restricted at EMCF and as of March
2021, EMCF employed 166 female officers, indicating that 46 percent of officers are
female. Based on our discussions with subject matter experts, we believe that increasing
that percentage to 60 or 70 percent could begin to tip the scales favorably on some of the
A greater number of female officers at EMCF would enable greater female oversight
of and participation in cell extractions, which Commissioner Hicks agreed should be a goal.
Protocols should be reviewed with an eye towards decreasing the involvement of male
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ii. Explore Corrections Officer Recruitment and Retention
Strategies
Even with the above as a goal, our interviews revealed that NJDOC has had
difficulty recruiting high-quality staff and female officers to EMCF, particularly because
of its remote location and the starting salary. The starting salary for an entry-level NJDOC
seeing significant turnover of staff in their first five years due to the salary not being
competitive, resulting in the loss of top-performing employees to other State agencies that
offer higher salaries in more attractive geographic locations. For example, NJDOC’s chief
of staff noted to us that certain county jails offer their corrections officers significantly
more money than what NJDOC can offer. In short, top law enforcement candidates often
can find work that is both safer and higher-paying. In view of the recent $20.8 million civil
top candidates may ultimately be cost-effective for the State. Greater pay also could be a
component of union negotiations relating to some of the other issues referenced in this
report.
NJDOC should consider whether all posts require correctional officers to be trained in the
use of firearms and carrying a firearm on duty. Applying for a role that requires the
individual to train in and carry a firearm may deter some applicants who would otherwise
be qualified. A corrections consultant informed us that another state had some success
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Moreover, we recommend that State policymakers consider whether to exempt
EMCF from the New Jersey First Act, N.J.S.A. 52:14-7, which imposes New Jersey
residency requirements on most State officers and employees. Allowing EMCF to expand
its recruitment efforts to people who live in Pennsylvania, which is less than 20 miles from
EMCF, would increase the pool of potential candidates. It is vital to the success of the
officers.
EMCF should revisit its curriculum for gender-responsive training with an eye
consultant we interviewed noted that the current level of training that new staff receives
appears to be inadequate in these areas. Using de-escalation efforts before resorting to the
EMCF also should develop a more robust practical training program for cell
extractions. Several people we interviewed as part of our investigation noted that such
of order, fairness and predictability. Along these lines, we found stark differences in
perspectives between staff and inmates about the culture within the facility and their
relationship with each other. Inmates reported that no one is looking out for them and their
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rights are being abused. On the other hand, officers have reported that the inmates are
effectively in control of the facility and that inmates do not respect their authority. Though
upon visiting EMCF’s RHU. She was surprised to find inmates yelling at her using vulgar
language as she walked through the unit. She remarked that it is unusual for female inmates
in restrictive housing to feel comfortable interacting with third parties in that manner.
We recommend that as part of the ongoing work of the consultant currently engaged
at EMCF, attention be directed at the perspectives and attitudes of the inmates and staff.
The consultant should speak with stakeholders, observe the environment and make
recommendations for improvement, focusing on bridging the gap between staff and
inmates to facilitate a more effective relationship between the two groups. Progress must
For the reasons stated previously, NJDOC should complete and monitor
implementation of its EWS and new BWC policy. NJDOC should use its EWS to more
aggressively screen for potential problematic conduct by its correctional officers and
consider appropriate (re)assignments for those officers, before significant misconduct takes
place. It is consistent with common sense, moreover, that use of body cameras will
promote proper conduct on the part of anyone being recorded, officer or inmate.
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5. Physical Facility
Lastly, in view of the lengthy negative history of misconduct at EMCF, whether that
conduct can best be shifted to the past by closing the facility altogether should be
corrections, questioned, in light of the momentum of negative issues at and attention to the
facility, whether EMCF can be “saved” in a reasonable amount of time. In light of our
findings, we recommend that NJDOC consider closing down EMCF and relocating its
With the facility being more than 100 years old, it is in any event in need of
encountered difficulty recruiting female staff to EMCF’s location in western New Jersey.
A different, more centrally located facility has the potential to address these issues.
On May 3, 2021, Commissioner Hicks testified before the New Jersey Assembly
Budget Committee that during his administration, NJDOC has shut down two prisons and
intends to close a third facility, which is located approximately six miles from EMCF. He
testified that NJDOC saw a decrease of approximately 5,000 inmates across all of its
facilities from 2020 to 2021, indicating that space considerations at NJDOC facilities may
not be as critical as previously had been the case. In our interview with him, Hicks agreed
that the feasibility of a shut-down of EMCF should be explored. While the expense and
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effort associated with a closure, and transfer of inmates, would be significant, the State
may find another valuable purpose for the many acres of land on which the facility sits.
be incarcerated so there is more than one New Jersey correctional facility that can house
female prisoners. NJDOC officials and EMCF supervisors we interviewed said the fact
that EMCF is New Jersey’s only women’s prison makes it very difficult to effectively
separate inmates from staff or other inmates with whom they have continuing issues. They
noted that male inmates are frequently transferred between correctional facilities in New
Jersey as a way to halt patterns of bad behavior and provide a “change of scenery,” an
opportunity that EMCF inmates are not afforded. Under this alternative, EMCF would
continue to operate and exist, but with a reduced population. Its inmates could be
transferred when deemed necessary or to better separate an inmate from an accused staff
The availability of another location for female inmates also would further facilitate
EMCF’s compliance with PREA requirements. Currently, separating an inmate who has
alleged sexual abuse from her alleged abuser may require temporarily placing her in
segregated housing, which inmates may view as punitive. See 28 C.F.R. § 115.43. Access
warranted to ensure the safety and wellbeing of inmates and staff. Multiple interviewees
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For example, the “broken windows theory” posits that “disorder and crime are usually
inextricably linked.” George L. Kelling & James Q. Wilson, Broken Windows, The Police
https://www.theatlantic.com/magazine/archive/1982/03/broken-windows/304465/; see
also Roger P. Alford, A Broken Windows Theory of International Corruption, 73 Ohio St.
L.J. 1253, 1256–57 (2012); Louise A. Ellis, et al., An Empirical Application of “Broken
Windows” and Related Theories in Healthcare: Examining Disorder, Patient Safety, Staff
Outcomes, and Collective Efficacy in Hospitals, BMC Health Servs. Rsch. 20, 1123 (Dec.
theory as it relates to the effect of disorder on staff and patients in hospital settings). “One
unrepaired broken window is a signal that no one cares, and so breaking more windows
https://www.theatlantic.com/magazine/archive/1982/03/broken-windows/304465/.
At EMCF, the disrepair of the physical facility can signal to inmates, as inmates
indicated during our interviews, that because the State does not “care” enough to fix the
facility, it does not care about the inmates or their behavior, good or bad. This also applies
to staff members. Research has shown that in environments where individuals have a lack
of control over certain stressors, the individual may “react with anger, blam[e] others, . . .
or [engage in] aggressive retaliation.” Ruthanne DeWolfe & Alan S. DeWolfe, Impact of
Prison Conditions on the Mental Health of Inmates, 4 S. Ill. U. L.J. 497, 508–09 (1979).
“In order for a correctional building to function as a tool for rehabilitation, the design of a
correctional facility should: [be] based on the premise that people are capable of change
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and improvement, with the built environment conveying the message that incarcerated
people are worth something.” Marayca López, How to Build for Success: Prison Design
and Infrastructure as a Tool for Rehabilitation, Penal Reform Int’l (July 24, 2014),
https://www.penalreform.org/blog/build-success-prison-design-infrastructure-tool-
rehabilitation/. “Older jails, some built more than a century ago, can also pose significant
health and safety risks to both staff and the incarcerated population through [their]
designs.” Chris Mai, et al., Broken Ground: Why America Keeps Building More Jails and
https://www.vera.org/downloads/publications/broken-ground-jail-construction.pdf. A
functional facility needs to provide basic, minimum living conditions (e.g., clean water,
functioning toilets and sinks, natural light), while allowing for the proper regulation and
The problems associated with EMCF’s facility have been documented elsewhere,
including in legislative testimony. These include electrical issues and other problems
related to the facility’s outdated infrastructure. For example, on May 10, 2021, it was
publicly reported that EMCF suffered a power outage beginning on May 8, and although
power was restored to most of EMCF a few hours later, power was out for about 40 hours
in the Stowe and Randall buildings, which temporarily left almost 200 inmates without
electricity until they were moved to other housing areas. In late April, there had also been
reports of mold in the facility’s Hillcrest housing unit, which was described as “black
sludge found in sinks, drains, toilets and showers, leaking sewage, brown and black water”
by reporting sources. Inmates in that unit were transferred to other housing units. While
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it is beyond the scope of this investigation to examine such issues in detail, it was nearly a
universal sentiment across our investigation that the poor condition of the physical facility
has contributed to low morale among both inmates and staff and interfered with best
The abandoned buildings on the site have presented additional opportunities for
abuse. Though those buildings now are locked and tagged in a manner that makes
unauthorized entry unlikely, in the past they have been used by correctional officers as a
place to engage in illegal sexual acts. In short, the structure and design of the facility itself,
in addition to its condition, provides unique challenges for both facility staff and inmates.
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