A Disability Rights NC Report on NC’s Failure to Regulate Dangerous Jails
This report is DRNC’s first comprehensive public report examining and exposing North Carolina’s (NC’s) deeply flawed and dangerous jail regulatory system. This report builds upon our previous work analyzing the persistently dangerous conditions in our state’s jail system. DRNC’s investigation uncovered facilities that were allowed to operate despite chronic inspection failures and dangerous conditions, sometimes with deadly consequences.
Jails are an important part of our state’s public safety system, separate and distinct from our state’s prisons. Most of the people held in jails are there following arrest and have not had a trial; they have not been convicted of a crime. A small percentage of people incarcerated in local jails have been convicted of low-level crimes, usually misdemeanors, and are serving short sentences.
NC’s county jails are operated locally, with responsibility for their operations falling to the elected sheriff. They are funded by the local county commission. A few counties combine resources to operate a regional jail; these are funded by the counties involved.
In contrast, people who are in prison have been convicted of crimes, and many of them are serving longer sentences. NC’s prison system is overseen by the state Department of Public Safety, which is funded by the NC General Assembly.
This report focuses exclusively on our state’s 109 jails.
DRNC staff reviewed more than 600 NC Department of Health and Human Services (DHHS) Division of Health Service Regulation (DHSR) jail inspections from 2017-2019 to investigate the safety of NC jails and the effectiveness of State oversight. As part of the investigation, we also requested and reviewed related Plans of Correction (POCs), official correspondence regarding the inspections, Medical Examiner death investigations, DHSR death investigations, and autopsy reports. In addition, we examined years of Local Confinement Reports (LCRs), which local jails submit to DHSR capturing daily census counts. Using the LCRs, we studied jail populations and overcrowding. DRNC obtained all documents through public records requests to DHHS and, while DHHS did not provide DRNC with a complete dataset for every facility, the volume of reports we received provides an accurate picture of jails and jail regulation in North Carolina. All statistics contained in this report are based on public records released by DHHS.
Overview of Regulatory System
A meager three-person team at DHSR is responsible for evaluating compliance with Jail Rules throughout the entire state, encompassing 109 jails and local detention facilities. The Jail Rules establish minimum safety standards each jail must comply with. The three-person DHSR team investigates complaints and deaths, provide technical assistance, and are responsible for conducting over 200 bi-annual inspections of NC jails every year. These responsibilities are enormous, time-consuming endeavors for a small team.
When a jail fails inspection, DHSR sends a letter to the sheriff, county commissioners, and jail administrators requiring them to develop a “Plan of Correction” (POC). A POC is then developed by the sheriff, who sends it to DHSR for review and approval. DHSR approves the vast number of these POCs.
If a jail’s conditions are dangerous to jail staff or the people in custody, the DHHS Secretary may close the jail or force corrective action. This is the only enforcement mechanism available to DHHS to bring chronically problematic jails into compliance with Jail Rules. The closure/forced corrective action process involves a long period of required notifications and a chance for administrative appeal.
Overview of Inspection Failures
Analysis of DHHS records from 2017-2019 revealed that NC jails failed a total of 375 inspections, or 62% of all inspections. Forty-one facilities (37.6%) failed every single inspection, and 13 facilities failed between 80-99% of their inspections. In contrast, only 15 (14%) passed all of their inspections, and an additional 13 facilities failed just one inspection.
 DRNC considers an inspection “failed” when DHSR cites a facility for non-compliance with the Jail Rules, meaning that the inspection found the facility was not following one or more of the Jail Rules.
 DRNC did not receive all the inspections conducted during 2017 – 2019.
Figure 1. Cumulative Inspection Results From 2017-2019
*Two facilities were evacuated during inspection due to natural disasters (hurricane)
Figure 2. Failure Rates of all Facilities
Overview of Jail failures
As part of our review, DRNC categorized jail inspection data based on the following types of failures:
- Supervision Failures: Failing to monitor people in custody as required by the Jail Rules. This includes missing supervision rounds, broken surveillance equipment (cameras, two-way communication), failing to directly observe on supervision rounds, failing to conduct supervision rounds at the proper times, and failing to place someone on special watch versus regular watch.
- Capacity Failures: Operating a jail that is overcrowded beyond the total design capacity. While jails are not in violation of the Jail Rules until they reach 100% of design capacity, there is consensus among corrections experts that a population above 80% is dangerous to everyone in the jail, staff included. NC also has statutory provisions stating that jails must be adequately staffed to ensure the safety and proper care of everyone in the facility.
- Medical Failures: Failing to maintain a proper health plan for people in custody as required by the Jail Rules or maintain proper medical equipment.
- Construction/Sanitation Failure: Failing to maintain clean and properly functioning facilities. This includes failing to maintain clean showers/HVAC systems, violations of NC Construction Code, and dangerous conditions caused by breakdown of physical fixtures of the jail.
- Fire Failure: Failing to maintain a proper fire detection and prevention system (e.g., sprinkler system) and any other violation of the NC Fire Code.
 See https://disabilityrightsnc.org/prisons-and-jails/state-jail-program-tied-overcrowding/, U.S. Department of Justice National Institute of Corrections. Sheriffs’ Guide to Effective Jail Operations (2007), 23.
 N.C.G.S. 153A-224
Details of Jail Inspection Failures
- 86% or 324 inspection failures were due to inspection failures for construction/sanitation issues.
- 38% or 143 inspection failures were for supervision issues.
- 29% or 110 inspection failures were due to overcrowding.
- 20 % or 76 inspection failures were for fire safety issues.
- 4.8% or 18 inspection failures were for having inadequate health plans. It is important to note, however, that state Jail Rules have few requirements for what health plans must cover, making this metric harder to accurately capture.
Figure 3. Number of Inspection Failures by Failure Type Statewide from 2017-2019
Chronic Issues and Repeat Failures
DRNC categorized instances in which jails failed multiple inspections for the same or similar issues over a span of months or years. DRNC designated a facility as having a “General Chronic Problem” with maintaining a safe, compliant jail environment when a facility failed three or more inspections within the same failure category. For example, a facility that failed three different inspections – once for a broken surveillance camera, once for missed supervision rounds, and once for failure of direct observation – has a General Chronic Problem in the category of supervision failures.
DRNC designated a facility as having a “Specific Chronic Problem” when a facility failed three or more inspections for the same reason within a category. For example, a jail that failed three different inspections for broken cameras would have a Specific Chronic Problem in the category of supervision failures.
In 211 instances, a facility failed an inspection for the exact reason it failed the previous biannual inspection. As shown in Figure 4, often these repeat failed inspections indicated serious safety concerns. From 2017-2019, approximately 59% of the 109 jails had a chronic failure problem. Significantly, half of the state’s 109 facilities had specific chronic problems, meaning they failed at least three inspections for the same issue. Nine others had general chronic problems, meaning they failed at least three inspections for Jail Rule violations in the same category.
Figure 4. Number of Repeat Failures for Identical Issues from 2017-2019
The 9 facilities with general chronic problems were due to construction/sanitation failures. The 55 facilities with specific chronic problems repeatedly failed inspections for Supervision, Capacity, Construction/Sanitation, and Fire Safety and Medical Plan violations as shown in Figure 5.
Figure 5. Number of Facilities with Chronic Inspection Issues Versus No issues
These repeated failures led to dangerous environments for people in custody and jail staff. Several facilities had supervision failures for missed rounds, failed two-way communications systems, or other serious supervision lapses. Other facilities repeatedly failed inspections for fire safety issues or for dangerous overcrowding.
Figure 6. Number of Facilities with Specific Issue Problems by Problem Category
DHSR Enforcement Responses
Given the widespread and dangerous chronic jail safety problems detailed above, DRNC analyzed over 200 POCs and corresponding DHSR responses to investigate DHSR’s methods and effectiveness of jail regulation. According to DRNC’s analysis of over 200 POCs and corresponding DHSR responses, DHSR approved 99% of POCs from 2017-2019, despite facilities having chronic safety issues that were not corrected. DHSR only rejected three POCs and two of these facilities failed later inspections for the same reasons. DRNC found that POCs overwhelmingly did not fully correct the safety issues found in NC’s jails.
In 26 cases, DHSR accepted POCs that only partially addressed the violations in the inspection report. In 58 cases, DHSR accepted POCs even though the sheriff denied that the original cited condition existed or stated that coming into compliance was impossible. In 119 of the 211 instances when a facility failed an inspection for the same reason it failed previous inspections, records show that DHSR had accepted the sheriff’s initial insufficient POC only to have the jail fail the next inspection for the same reason. Our investigation found no instance where repeat failures or specific chronic failures led to jail closures.
Our analysis shows a pervasive pattern of DHHS declining to impose meaningful corrections or consequences for repeated jail safety violations. This results in persistently dangerous jail conditions in North Carolina that damage our communities and endanger the lives of incarcerated people and jail staff.
 Records provided for Beaufort County Detention Center indicated that DHSR rescinded several 2016 POC approvals due to a fire safety issue that, despite coming to the attention of DHSR in 2014, had not yet been resolved as of 2017. DHSR did indicate in a 2017 letter that failure to fix the issue could result in the closure of the jail.
Some of the jails with the worst safety records are discussed below.
Inaction Allows Dangerous Conditions to Persist
DHSR routinely accepts POCs in instances of repeat violations for the same non-compliant conditions. In these cases, the Secretary of DHHS could have ordered corrective action or closed these facilities based on failed inspections. Instead, DHSR continued to approve POCs year after year despite persistent dangerous conditions.
A. Deadly Consequences – Regulation Failures Linked to Deaths
In May of 2017, Byron Bradshaw died in Rowan County Detention Center (Rowan CDC). DHSR found that officers missed safety supervision rounds, failed to place Mr. Bradshaw on four times per hour supervision, and that the facility failed to provide Mr. Bradshaw with proper medical care. LCRs show that the part of the jail housing males was overcrowded on the day Mr. Bradshaw died – at 108% capacity, far above the safe level of 80% or below.
The jail failed its next two inspections for missing supervision rounds. They failed a third inspection for being dangerously overcrowded at 109%. Despite these conditions, DHHS took no action to close the jail.
In September of 2019, two more people died in the Rowan CDC. James Rife and Julie Beach died about two weeks apart in September of 2019, both from overdoses. DHSR investigations into both deaths showed the same failures as the 2017 death – missed safety supervision rounds. The jail was grievously overcrowded during the time Rife and Beach died – between 112% and 114%.
A few months later, in January of 2020, the jail was again cited for overcrowding, but still no actions were taken to close the jail. Tragically, 53-year-old Larry Hood died by suicide in Rowan CDC in October of 2020. In its subsequent death investigation, DHSR again found the facility failed to properly conduct supervision safety rounds.
In March 2018, Richmond County Jail (Richmond CJ) failed its third consecutive biannual inspection for being dangerously overcrowded. The inspection noted the jail had been over capacity for the last two years, and that the overcrowding created a “potential unsafe condition for detention officers and inmates”.
One of the symptoms of overcrowding is missed safety rounds, as there are not enough staff to properly supervise those incarcerated. Inspections reviewed show repeated failures for overcrowding dating back to January 2014. Despite this ongoing history of dangerous conditions, DHSR did not close the jail or force corrective measures.
 See U.S. Department of Justice National Institute of Corrections. Sheriffs’ Guide to Effective Jail Operations (2007), 23: “Basic functions (security, maintenance, sanita tion, programs, recreation, etc.) begin to break down when they are stretched to their limit for extended periods of time due to crowding. These conditions increase the jail’s liability exposure and jeopardize the safety and well-being of both inmates and staff.”
On June 14th, 2018, Adrian Campbell died of a heart condition in Richmond CJ. A DHSR death investigation found that the facility missed several supervision rounds around the time of Mr. Campbell’s death, and that the camera system in the block holding Mr. Campbell was not working. The day Mr. Campbell died, the jail was severely overcrowded, at 130.5% of capacity. The jail had failed an inspection for being overcrowded three months before Mr. Campbell’s death.
On June 26th, 2018, five days after DHSR completed their death investigation into Mr. Campbell’s death, the jail failed another biannual inspection for being overcrowded.
A month later, the jail submitted a POC in response to the failed death investigation which stated they were “working with the DA” (District Attorney) to ease overcrowding” after Mr. Campbell’s death, but also admitted they were still overcrowded This was the same POC they had submitted in response to a failed inspection in January of 2018, six months before Mr. Campbell’s death.
Two days later, DHSR accepted Richmond CJ’s proposed POC in Mr. Campbell’s death. Richmond CJ went on to fail their next inspection for being dangerously overcrowded. Their proposed solution, again, was to work with the DA to get numbers down.
Richmond CJ remained extremely overcrowded through 2019, 2020, and 2021, and remains alarmingly overcrowded. In the first half of 2022, the jail averaged between 132% and 168% capacity, over double the nationally recognized safety limit of 80%. It was, and is, one of the most overcrowded jails in North Carolina.
Jail Rules require that each jail maintain modes of supervision in addition to in-person supervision, one of which can be a two-way communication system. After a person in Vance County Detention Center (Vance CDC), Benjamin Mallard, died in his cell from withdrawal in February 2019, the subsequent DHSR death investigation noted both missed supervision rounds and a lack of a two-way communications system, a clear violation of Jail Rules. For at least two years, Vance CDC did not have a working a two-way communication system for over half of the beds in their facility. Four months after Mr. Mallard’s death, the jail was cited for the fifth time for the broken communications system.
With every failure, the jail submitted the same solution in their POC – that an officer would sit in front of the dorms that didn’t have a two-way communications system so they could hear everything going on in the cell block. This officer was to be responsible for monitoring 95 beds, replacing two-way communications in six areas of the facility. Based on a review of available records, DHSR accepted this inadequate solution each time the jail presented it, even while continuing to cite them for a broken two-way communications system.
 10A NCAC 14 J .1600 (b)
 DRNC was not provided with an acceptance letter for the jail’s POC to the 8/8/2018 inspection failure, however records indicate the problem still existed at the next inspection and DRNC received no documents indicating any further steps were taken to address the failure.
Between 2017-2021, eight incarcerated people died in the Edgecombe County Detention Center (Edgecombe CDC)J, including four who died by suicide, even while state regulators repeatedly cited the jail for failing to supervise people as required by law. In five of those deaths, three of them suicides, subsequent DHSR investigations found serious failures to follow Jail Rules.
On May 31, 2017, Edgecombe CDC failed a biannual inspection for, among other things, failure to properly conduct safety supervision rounds. A little over two weeks later, Thomas Kinsley died by suicide in the jail. The facility failed the subsequent DHSR death investigation, which cited the jail for conducting only a small fraction of the supervision rounds required by law and allowing the entire jail to go unsupervised for hours. Further, when they did conduct rounds, the officers did not look into Mr. Kinsley’s cell.
Five months after Mr. Kinsley’s death, in November of 2017, the jail again failed a biannual inspection. As with the last failure, the jail failed to properly conduct safety supervision rounds. Again, DHSR took no action to close the jail or force corrective action.
A month after this failed inspection, DHSR accepted the POC submitted by the sheriff in response to the supervision failings found during DHSR’s investigation into Mr. Kinsley’s death.
A few weeks later, on January 4, 2018, Johnny Harris died in the Edgecombe CDC. The DHSR investigation into his death found that jail staff failed to perform a number of required supervision rounds. In response to these rule violations, the Edgecombe CDC submitted a POC stating they would “continue to enforce policy” surrounding supervision rounds and would discipline any officer not in compliance. DHSR accepted this plan in April 2018.
Less than a year later, in March of 2019, Donta’ous Devine died by suicide in Edgecombe jail. As with the other deaths, DHSR’s investigation into Mr. Devine’s death found significant supervision failures. Specifically, DHSR found that officers failed to perform two dozen supervision rounds, and that “officers made supervision rounds but did not pay close attention observing inside the inmate’s cell and did not check to see if the inmate was okay.” The report further noted that “officers did not initiate lifesaving attempts” to save Mr. Devine.
The Death Report filled out by the jail indicated the last supervision round where Mr. Devine was confirmed alive was conducted hours before Mr. Devine’s death – at 11:20 p.m. the night before – a serious violation. The autopsy indicated that guards saw paper covering Mr. Devine’s cell window in the early morning hours before he was found dead but did not check on him – another violation. Guards did not find Mr. Devine hanged in his cell until the next morning during daily head count. By the time EMTs arrived, Mr. Devine was cold to the touch and had clear signs of rigor-mortis.
Two months after Mr. Devine’s death, the jail failed yet another biannual inspection for failing to perform supervision rounds. Two months after that, DHHS accepted the jail’s POC from Mr. Devine’s death investigation. In this POC, the jail again promised to enforce rounds and take corrective measures when officers failed to make rounds. This is astoundingly similar to the POC the jail submitted after Mr. Harris’s death in 2018, a plan that clearly failed to remedy the supervision failures.
In October 2019, seven short months following Mr. Devine’s death, Jeffrey Morris died in the Edgecombe County Jail. In their investigation of Mr. Morris’s death, DHSR investigators learned mental health staff visited Mr. Morris the day before his death. Mental health staff warned that he should be in the least isolated setting possible. Mental health staff said Mr. Morris was paranoid, hearing voices, was “disheveled,” hallucinating, and might require hospitalization.
Shockingly, after his visit with mental health staff, Mr. Morris was put into a segregation cell by himself. Mr. Morris hung himself the next day.
DHSR’s investigation documents that no one checked on Mr. Morris for over two hours before he was found dead, despite the mental health staff’s warnings. The investigation also found that “review of the documented supervision rounds found that officers were not actually making their rounds; and . . . that in fact, the officers were doing other activities.”
As with the deaths of Mr. Harris and Mr. Devine, the jail responded to the failures identified in Mr. Morris’s death investigation by submitting a POC stating that officers had been reminded to properly perform rounds, and that “corrective action” was taken against officers responsible for not making rounds. DHSR accepted this POC in March 2020 with no further inquiry, citation, or action.
In November 2021, Joshua Clark died in custody at Edgecombe CDC. Yet again, a DHSR death investigation found jail staff failed to properly perform supervision rounds. Yet again, the jail submitted a POC stating that they would remind staff to conduct supervision rounds, and that corrective action would be taken on jail staff who missed rounds. Again, DHHS accepted this POC without further action.
B. Falsifying Inspection Documents and Myriad Safety Violations: Ashe County
Ashe County Detention Center (Ashe CDC) failed 10 DHSR inspections from February of 2017 to November of 2019. The Ashe CDC was cited in 7 inspections for failure to properly supervise people in custody, and cited in 6 inspections for fire safety violations. Repeatedly, the jail was permitted to remain open while hazardous conditions persisted. They were not subject to corrective action or jail closure even though these violations warranted immediate action according to Jail Rules.
In most instances, DHSR accepted the POCs submitted by Ashe County without requiring evidence that the POCs would improve safety conditions. DHSR also failed to ensure the implementation of remedial actions outlined in the POCs. These failures, described below, show a troubling pattern in which actions by jail staff resulted in dangerous safety violations that were allowed to continue despite increased state oversight. Most troubling, DHSR’s increased oversight uncovered several instances of jail staff falsifying supervision and fire safety records in order to pass inspection. Despite these findings, no action was taken to close the jail or hold jail staff or the sheriff accountable.
Ashe CDC failed a February 2017 inspection report for:
- Multiple safety violations, including fire safety violations
- Obstruction of windows impeding observation
- Unauthorized restraints added to restraint chair
- Males and females housed in the same area
- Lack of privacy in female sleeping and shower areas allowing incarcerated women to be visible to male jail staff
Ashe CDC failed a May 2017 inspection for:
- Missing quarterly fire drills
- Falsifying fire drill documentation
- Multiple safety violations
Ashe CDC failed a November 2017 inspection report for:
- Failing to properly supervise people in their custody
- Irregularly completed rounds as opposed to regularly scheduled rounds at specified intervals
- Insufficient staff ratios – at times, only 2-3 staff were supervising up to 165 incarcerated persons
- Falsifying supervision rounds
Ashe CDC failed a December 2017 inspection for:
- Neglecting to properly perform safety supervision rounds
Ashe CDC failed a January 2018 inspection for:
- Not properly supervising those in their custody
One month later, Ashe CDC failed its February 2018 inspection for:
- Not properly supervising those in their custody – DHSR noted that “the remote electronic monitoring digital video recording (DVR) units’ times are not consistent with the actual time the video was recorded.”
Three months later, Ashe CDC failed a May of 2018 inspection for:
- Failing to perform supervision rounds
- Failing to perform required fire drills
Ashe County CDC failed an inspection at the end of 2018 for:
- Not utilizing disciplinary procedures listed in the Jail Operations Manual
- Not having a hearing officer
- Not providing those incarcerated with the opportunity to contest infractions
- Allowing incarcerated people to start fires with electrical outlets
- Allowing incarcerated people to wear personal clothing items
- Broken surveillance cameras
These repeated failures show that our current system of regulation is not effective. Even under the added scrutiny of increased inspections, DHSR allowed dangerous jail conditions to persist unabated as Ashe CDC continued to fail inspections with no consequences.
However, DHSR’s increased inspections of Ashe County uncovered shocking details: DHSR investigators reported instances of Ashe County jail staff falsifying records in order to pass inspection.
In an inspection report dated May 10, 2017, DHSR noted the following:
“It was reported that quarterly fire drills have never been performed. It was further reported that the administration would require staff to sign a document stating a fire drill was conducted, but without a fire drill being performed.”
During the previous inspection on Feb. 14, 2017, DHSR had cited Ashe CDC for serious fire code violations including improper storage of propane tanks and a gas grill, unsecured electrical receptacles, and storing flammable materials too close to electrical panels—making Ashe CDC’s attempt to cover up a failure to perform fire drills especially alarming. Despite this finding, DHSR accepted a POC from Ashe CDCy that neither explained nor addressed the fraud, and the jail suffered no consequences for falsifying fire drill reports.
Six months after discovering falsified fire safety documents, DHSR again found evidence that jail staff had been falsifying documents to make Ashe CDC appear to be in compliance with the Jail Rules. The Nov. 8, 2017 inspection report noted:
“supervision rounds were documented as being conducted, but video indicated that supervision rounds were not conducted.”
The inspection also found that officers were not looking into the cells as required when rounds were conducted. Staff interviews during this inspection showed a pattern of understaffing and lax enforcement of supervision rounds in direct violation of the Jail Rules. When confronted with this fraud, Ashe CDC stated in their POC that “if for any reason [jail staff] did not do a round they will not write down that they had done the round because that would be falsifying records.”
The POC included no mention of any disciplinary action taken against the staff who falsified supervision round logs. DHSR accepted the sheriff’s proposed POC, and the jail suffered no further consequences for this second instance of fraud. Appendix A of this report provides details of subsequent failed inspections including fire safety and supervision, even after DHSR required POCs.
For more details on Ashe’s history of failed inspections and dangerous conditions, see Appendix A.
C. Repeated Dangerous Overcrowding
As DRNC previously reported in August 2021, overcrowding in jails is rampant and dangerous. According to national corrections experts, when jails reach about 80 percent capacity, the basic processes of a jail, such as security, maintenance, sanitation, programs, and recreation begin to break down in ways that “jeopardize the safety and well-being of both inmates and staff.” This is not hard to imagine; overcrowded jails mean overworked staff who often cannot maintain the level of security necessary to keep themselves safe or perform the required supervision rounds to keep the people in the cells safe.
Nevertheless, state regulations only require jails to maintain populations under 100% of rated capacity. To track these numbers, each month NC’s jails are required to report daily census numbers to DHSR in LCRs. Based on LCRs from 2018-2021, 27 facilities reported yearly averages of over 100% capacity. Several of these facilities reported being over capacity every month of the year. Some others, like McDowell CDC, regularly fail inspections for being over capacity in addition to serious supervision failures. At least two counties, Johnston and Gaston, were allowed to remain over capacity for years while the counties planned and built new jails or jail additions.
 https://disabilityrightsnc.org/prisons-and-jails/state-jail-program-tied-overcrowding/; U.S. Department of Justice National Institute of Corrections. Sheriffs’ Guide to Effective Jail Operations (2007), 23.
Nineteen jails reported being over capacity in the first four months of 2022. Eleven of those 19 jails were also over capacity in 2021. A simple solution is available; open beds in other county jails can be used to alleviate overcrowding. The severe overcrowding of recent years is particularly troubling given that the Jail Rules, effective September 2020, require jails to immediately move people out of overcrowded facilities.
Statewide, North Carolina jails have never had more people in custody than there were jail beds available. Given the availability of beds statewide, the fact that many jails continued to operate while dangerously overcrowded in blatant violation of the Jail Rules is particularly troubling.
Below are some examples of these overcrowded facilities.
The Johnston County Jail (Johnston CJ) failed every DHSR inspection from 2017-2019 for being overcrowded. Johnston CJ reported being under capacity for only 17 days from 2018- 2021. Johnston CJ averaged between 128% and 155% capacity every month from October 2021 to August 2022. Several POCs that Johnston CJ provided to DHSR blame the crowding on delays in construction of a new jail. DHSR’s investigation found that, the jail expansion has been in progress since at least 2015 and is incomplete as of November 2022.
 DRNC did not receive accurate daily population numbers for March, July, and August 2018 and January 2019.
 April 2022 is the latest month for which DRNC has population records.
On June 13, 2017, Carteret County Detention Facility (Carteret CDF) failed its first biannual inspection of the year in part due to significant overcrowding. The inspection noted that the jail was at 118% capacity. Both the male and female sections of the jail were overpopulated. The inspection noted that the jail had been over capacity for the past two years.
This failed inspection would not be its last for overcrowding. Carteret CDF failed every inspection DRNC has on file from 2017-2019 for being overcrowded. In 2017, Carteret CDF reported being under capacity for only two days out of the entire year. During those days, they reported being at 99% capacity. During 2018, the jail reported being over capacity every day except seven days in May, when the jail was between 95% and 100% capacity. This trend continued into 2019, with the jail reporting being over capacity every day except 6 days in September when the jail was between 95% and 100% capacity.
DRNC’s review of Carteret’s self-reported LCR numbers to DHSR shows Carteret CDF misstated their population numbers on POCs and in letters to DHSR regarding population reduction. Although DHSR could have verified the jail’s stated population numbers using Carteret’s monthly LCRs, they did not. DRNC’s investigation found no serious efforts by DHSR to hold Carteret CDF accountable for keeping their promises of reducing the jail population.
Despite continuous overcrowding and multiple failed inspections, DHSR accepted POCs from Carteret CDF that repeatedly failed to bring the population to safe levels. None of these POCs were implemented and Carteret CDF has never successfully kept its population down.
Based on LCRs from 2020, 2021, and 2022, Carteret CDF continues to operate at well over capacity. Based on a recent inquiry by DRNC staff, DHSR allowed Carteret CDF to continue operations despite being severely overcrowded for the first eight months of 2022, averaging between 130% and 143% of capacity.
Carteret CDF operating far over capacity—even after specific changes in the Jail Rules aimed at reducing overcrowding—illustrates the failure of DHHS to implement the necessary regulations to keep jail staff and people in custody safe.
For more information on Carteret CDF’s chronic overcrowding and DHSR failures to bring the jail into compliance with the Jail Rules, see Appendix B.
 DHSR sent a warning to Carteret in July of 2019 to come into compliance with capacity limits or potentially face the beginning of proceedings to force corrective action or close the jail. Carteret sent a POC back stating the facility was not under capacity, but they would try their best to “maintain as close to rated capacity as possible.” DHSR accepted this POC despite continued overcrowding
D. Failure to Correct Recurring Fire Safety Issues
In Orange County, DHSR found serious fire safety issues. The agency repeatedly cited Orange County Jail (Orange CJ) for serious fire safety violations, including one easily fixable violation that continued to persist for years despite multiple citations. DHHS never imposed any consequences on Orange CJ for these repeat inspection failures.
From 2017-2019, Orange CJ failed five out of six DHSR inspections for fire code violations. The first, in July of 2017, cited the jail for lack of documentation of fire inspections and quarterly fire drills as well as fire safety issues related to storage space.
Between January 2018 and July 2019, Orange CJ failed four inspections in a row for improper storage of combustible materials. DHSR repeatedly cited the jail for storing combustible materials in the main electrical room. DHSR also cited the jail for not having a compliant sprinkler system and for being overcrowded, along with other fire safety issues. Despite the repeated citations for improper storage of combustible material, DHSR accepted POCs throughout 2017-2019, all of which indicated the combustible materials had been removed. Again and again, DHSR accepted identical POCs submitted to fix a dangerous fire safety issue, only to find the issue had not been fixed at the next inspection.
The conditions in Orange CJ created an environment for incarcerated individuals and jail staff that jeopardized their health and safety. Improper storage of combustible materials, a sprinkler system at risk for failing when needed, and an overpopulated jail created highly hazardous conditions that would make evacuation dangerous or deadly.
 DRNC was not provided with documentation of acceptance of the 7/16/2018 inspection POC, but the problem persisted since the next inspection found combustible materials in the same place as the 7/16/2018 inspection.
E. Chronic Dangerous Supervision Failures
Jail Rules require jailers to check on the safety of incarcerated people at least two times per hour. The Rule requires more frequent supervision if an individual is on suicide watch or if they show certain risk factors during initial screening (e.g., intoxication or behavioral issues). DRNC’s investigation uncovered a staggering number of chronic, uncorrected supervision failures.
Swain County Jail (Swain CJ) was cited during each of its five inspections during 2017-2019 for missing dozens of supervision rounds. Several inspections found that there were hours-long periods of time where no supervision rounds were performed in the entire jail. An October 2018 inspection found that the electronic rounds recording system had not been recording rounds since July 2018. For months, there was no way for jail administrators to check that detention officers were performing proper rounds. Although the system was repaired during the inspection, records later sent to inspectors showed that in the two days following the inspection, jail staff missed dozens of required rounds.
Despite these multiple inspection failures, DHSR did not take any action to resolve issues found in Swain CJ. Four of Swain CJ’s submitted POCs promised to re-educate staff on the need for rounds, yet each time, the next inspection revealed the previous POC had failed to fix the lapse in supervision. Only in 2019, after two years of failed inspections for supervision failures, did the jail submit a POC stating that officers had been “reprimanded” for skipping rounds. No other details were provided.
 According to documents provided to DRNC, which did not include POC acceptance letters from Swain CJ
Several Jails Maintain Compliance with Jail Rules
This report focuses primarily on the alarming number of jails that routinely fail safety inspections and the similarly high rate of inspections documenting these failures statewide. It is worth noting that several jails either passed all their inspections or corrected problems within their facility after just one failed inspection. The minimum standards set by the Jail Rules are reasonable and can be readily met. These statistics also indicate that coming into compliance after a failed inspection is not an onerous process and that corrective actions can be completed in a timely manner. By complying with the Jail Rules and acting quickly to correct problems when they are identified, the jails described in Figure 7 created safer environments for people in custody and jail staff. Because the Jail Rules represent bare minimum safety standards and do not include regulations regarding things like staffing levels, a jail can still be dangerous and pass a DHSR inspection. However, passing all yearly inspections is a necessary first step to create a safe jail environment.
Figure 7. Facilities that Passed Inspections or Quickly Corrected Failures
|Facilities that Passed Every Inspection 2017-2019||Facilities that Failed Only One Inspection 2017-2019|
|Chatham County Detention Center||Alexander County Law Enforcement Detention Center|
|Currituck County Detention Center||Avery County Jail|
|Edgecombe County Detention Center Annex||Buncombe County Detention Center|
|Granville County Detention Center||Buncombe County Detention Center Annex|
|Hyde County Jail||Burke County Jail|
|Iredell County Detention Center Annex||Caldwell County Detention Facility|
|Mecklenburg County Jail North Annex||Carey A. Winters Detention Center (Wayne County)|
|Mecklenburg Work Release||Graham County Jail|
|Moore County Detention Center||Henderson County Detention Center|
|Pitt County Detention Center||New Hanover County Detention Center|
|Transylvania County Detention Center||Onslow County Jail|
|Wake County Detention Center||Polk County Jail|
|Wake County Jail Annex||Yancey County Detention Center|
|Wilkes County Detention Center|
Although the data is complex, the message it sends is clear – North Carolina jails need more rigorous oversight to ensure that jails are safe, and that jail staff are accountable to the communities they serve. DHHS is statutorily required to enforce the Jail Rules and ensure sheriffs are maintaining safe jail facilities. Every year, an increasing number of people die in NC jails. It is likely that an even larger number suffer serious injury, since jails are not currently required to release that data.
As outlined in this report and DRNC’s recommendations, DHHS is forced to work within an inadequate regulatory scheme that allows them only the impractical options of closing a jail through an arduous process or taking no effective action whatsoever against jails that repeatedly put their staff and people in custody at risk of injury or death.
DHHS’s current efforts are insufficient. The agency must change the way it addresses Jail Rule violations to ensure the safety of everyone in custody in NC jails.
North Carolina has a different system for regulating long-term care facilities and hospitals. When inspecting those facilities, DHSR has the authority levy various fines and to immediately order safety violations to be corrected before leaving the premises. By contrast, when a jail fails an inspection, there are no fines levied or immediate consequences for jail administrators. The state does not require jails to quickly address safety violations, endangering many lives. If the DHHS Secretary determines the failure jeopardizes safety, only then can DHHS order corrective action or close the jail. Jail closures are the Secretary’s only tool to force compliance with the Jail Rules, and it is an impractical, extreme measure that is difficult to impose. Sheriffs can appeal a decision to close a jail, adding cost and time to the process, and the difficulty of moving hundreds or thousands of incarcerated people to other jails can be daunting.
As this report lays bare, NC lacks a meaningful enforcement mechanism to make its jails safe. As described in DRNC’s recommendations, legislative action is required to give DHHS more immediate regulatory options beyond forced closure to bring jails into compliance
In addition, the DHSR jail regulatory staffing is insufficient for the work required of the team. Three people cannot effectively manage what is required of them: twice-yearly inspections of each of the state’s 109 jails, complaint investigations, death investigations, technical assistance to jails and sheriffs, responding to Sheriff’s appeals, and managing myriad POCs simultaneously.
While NC needs better regulatory schemes and more inspectors, it is ultimately the duty of the sheriffs to maintain safe jail conditions in day-to-day operations. All NC sheriffs are elected, and we urge every North Carolinian to become informed and involved in local elections to ensure that every elected sheriff is held accountable for the conditions of their jail.
You Can Help
- Vote Local
- Vote for sheriffs who are dedicated to operating safe jails. Sheriffs are elected officials. Learn about the conditions in your local jails and be informed when you vote.
- Vote for County Commissioners who support safer jails. County Commissioners control the budget for the jails. They can influence sheriffs and jail administrators to improve conditions in the jails.
- Speak Out
- Contact your State legislators. The more lawmakers feel this is an important issue to their constituents, the more likely they are to support positive change and call for the legislative measures DRNC recommends.
- Contact your local sheriff to voice your concerns about jail safety.
- Attend a meeting of your local Board of County Commissioners. Every Board has regular meetings open to the public that include opportunities for public comment. Voice your concerns about jail safety.
- Contact and support DRNC. DRNC continues to advocate for improved jail conditions. If you are interested in getting involved in local advocacy around jail issues, would like more information, or you or a loved one have experienced unsafe jail conditions, please contact DRNC.
DRNC thanks the University of North Carolina School of Law students who helped prepare this report:
- Wheels Moyer
- Claire Lieberman
- Katherine Bock
- Sunny Frothingham
- Olivia Clark
- Adrianne Cleven
Ashe County Detention Center (Ashe CDC) failed 10 DHSR inspections from February of 2017 to November of 2019. These failures, described below, show a troubling pattern in which fraudulent actions by jail staff and dangerous conditions are allowed to continue, even with increased oversight
In February 2017, a biannual inspection found that the entire jail was in a state of disrepair and had multiple fire safety violations. People in custody were allowed to keep street clothes in their cells. Direct observation was impossible in many of the cells due to blankets and towels obscuring windows. A restraint chair, already a dangerous tool of prison discipline, had extra unauthorized restraints added to it by jail staff, and there was no policy on when the chair should be used. Males and females were being housed in the same area, also against Jail Rules, and male jail staff could clearly see into the female sleeping and shower areas from a control room.
Likely because of Ashe CDC’s dangerous conditions, DHSR added extra inspections to try and ensure that Ashe County’s proposed POC’s were being implemented. Despite giving Ashe CDC repeat citations for supervision, construction, and fire safety issues—any one of which could have been grounds for facility closure—DHSR accepted every POC submitted by Ashe County during this time period. In our extensive record review, DRNC found no indication that the DHHS Secretary ever ordered corrective action or shut down the jail despite multiple identical inspection failures that endangered lives.
Inspection reports from Ashe CDC revealed strong evidence that jail staff were falsifying documents to make the facility appear to be complying with supervision and fire safety regulations, when in fact the facility was out of compliance. In one instance, the DHSR inspection found that jail leadership pressured staff to submit false documents.
During a May 10, 2017 inspection, Ashe CDC staff members told DHSR that jail administrators ordered staff to falsify fire drill reports. According to the inspection report, the quarterly fire drills required by law had never been performed. The inspection states:
 DHSR Inspection of Ashe County Detention Center, 05/10/2017, p. 3 of 6
DHSR cited Ashe CDC during the previous inspection for fire code violations, including improper storage of propane tanks and a gas grill, unsecured electrical receptacles, and storing flammable materials too close to electrical panels—making Ashe’s attempt to cover up a failure to perform fire drills especially alarming. Despite this falsifying of fire safety documents, DHSR took no immediate action, and the Secretary did not close or threaten to close the facility.
Instead, DHSR allowed the sheriff to submit a POC that did not address the falsified documents in any way nor promise compliance in the future. The POC stated only that “Employees had a surprise fire drill” and that the drill was entered into the shift log. Documents indicate that DHSR accepted the sheriff’s POC without further action. Ashe CDC would go on to fail four more inspections in the next two and a half years for fire safety failures, including failure to conduct regular fire drills.
In addition to fire safety violations, DHSR continued to cite Ashe County for additional serious safety violations, such as supervision failures. Despite myriad repeat failures, DHSR continued to accept every POC presented by the Ashe County Sheriff.
Six months after discovering falsified fire safety documents, DHSR again found evidence that jail staff had been falsifying documents to make Ashe CDC appear to be in compliance with the Jail Rules. DHSR inspection staff documented in the agency’s Nov. 8, 2017 inspection report, “supervision rounds were documented as being conducted, but video indicated that supervision rounds were not conducted.”
The inspection also found that officers did not look into the cells as required when rounds were conducted. Staff interviews during this inspection showed a pattern of understaffing and lax enforcement of supervision rules. Staff reported to inspectors that “rounds are made when staff can make rounds, and when staff does not have other duties to complete.” This directly violates the Jail Rules, which require supervision rounds at set specific intervals. Further, staff stated that “at times only two or three staff members are working in the jail.” The jail has a total capacity of 165 beds, far too many for only two staff members to supervise.
 10A NCAC 14J .0601
Once again, despite indications that staff violated Jail Rules, then falsified documents in an attempt to pass inspection, DHSR took no immediate action. The Secretary did not take steps to close down the facility, and the Sheriff was again allowed to submit a POC. The POC did not mention any disciplinary action taken against officers falsifying records, and only mentions a “mandatory meeting” wherein officers were reminded of their duties. In response to the fraudulent rounds, the POC states only “if for any reason [jail staff] did not do a round they will not write down that they had done the round because that would be falsifying records.” DHSR accepted this POC in December 2017.
In January 2018, Ashe CDC failed another inspection, in part for failing to properly supervise people in their custody. DHSR then wrote a letter to Ashe CDC, stating that the facility had failed the November 2017 inspection and two follow-up inspections for violating supervision rules. DHSR acknowledged that inspections found that it appeared the facility “had a common practice of not conducting a majority of the supervision rounds within a 24-hour period even though officers were documenting the rounds as being conducted.” While acknowledging that inspectors found fraud in supervision rounds documents, DHSR neither took actions to address the fraudulent record keeping, nor did they threaten corrective action or shutdown. Instead, DHSR stated that compliance with supervision rules needed to become a “common practice” at the jail and suggested that a minimum of seven officers be in the facility at any given time.
One month later, on February 13th, 2018, Ashe CDC failed another inspection for failure to properly supervise people in their custody. That inspection found that “the remote electronic monitoring digital video recording (DVR) units times are not consistent with the actual time the video was recorded.” DHSR responded to this failure by re-sending their letter from January and approving Ashe CDC’s POC two months later. The facility failed another inspection in May 2018 for, among other things, missed supervision rounds and having no documentation of fire drills. As with the previous inspections, DHSR took no action beyond accepting the facility’s POC.
Another inspection at the end of 2018 revealed that Ashe CDC was still a dangerous jail nearly two years after the failed February 2017 inspection. In addition to myriad fire code and construction violations, the inspectors found that the jail “does not use the disciplinary procedures listed in the Jail Operations Manual . . . the jail does not have a hearing officer, and inmates are not provided the opportunity to contest infractions, and are not permitted a hearing to present evidence regarding their infractions.” The inspectors also found, as in 2017, that incarcerated people were “wearing personal clothing items. . . throughout the facility”. Inspectors found “trash bags filled with water . . . throughout the detention blocks which could be used as weapons and/or to make alcohol type drinks” and “multiple books wrapped in garbage bags and tied together which could be used as weapons.” Inspectors also found that “[s]everal detention blocks had evidence that the inmates were using the electrical outlets to start fires,” making the facility’s failure to follow fire codes particularly troubling.
DHSR’s response was a strongly worded letter regarding issues with the fire alarms and generators. DHSR accepted the jail’s POC in February 2019, and the jail went on to fail its next two inspections – both for fire violations, including failure to perform regular fire drills.
On June 13, 2017, Carteret County Detention Facility (Carteret CDF) failed its first biannual inspection of the year, in part because the facility was significantly overcrowded. The inspection noted that the jail was at 118% capacity and both the male and female sections of the jail were overpopulated. At this point, overcrowding was nothing new to Carteret CDF – DHSR noted during the inspection that the jail had been over capacity for the last 24 months, dating back to at least mid-2015. LCRs submitted by the jail support this assertion, as Carteret CDF reported being over capacity for every day in 2017 leading up to the June inspection, often reporting being at 130-140% of total capacity or above.
DHSR notes that this level of overcrowding creates a “potential unsafe condition for detention officers and inmates,” yet DHHS took no action to enforce corrective measures or close the jail. DHSR allowed the Carteret Jail to present a POC, which stated that surrounding counties would be contacted to house the jail’s overflow, and that the jail would be “in compliance by 7/15/2017.” July 15 came and went with Carteret Jail still significantly over capacity, recording 121% capacity. According to LCRs filed by the jail, Carteret CDF remained dangerously overcrowded from the date of inspection through July 2017 until the middle of September, when they recorded two days at 99.1% capacity. Those two days were the only days during the entire year that Carteret reported being under capacity. Despite this continued overcrowding, DHSR accepted Carteret’s POC from the June inspection on July 18, three days after the facility had failed to live up to their promise of reducing their population by July 15th.
Carteret CDF failed their next 2017 inspection for being significantly over capacity once again, and again DHSR took no action beyond citation and allowing the jail to file a POC. This POC stated that as of 12/18/2017, the jail was “at its rated capacity with both male and female inmates.” It further stated that “as of 12/28/2017, the current jail population…is still at rated capacity.” DHSR accepted this POC.
 The LCR for the inspection date (6/13/2017) indicate the jail was actually at 132% capacity.
 The LCR for May 2017 does not include information about the jail population on 5/31/2017.
The December 2017 LCR filed by Carteret CDC directly contradicts the POC. On the LCR, Carteret reported that they were overcrowded every day of December of 2017 – on December 18, they reported being at 109% capacity, and on December 28th they reported being at 104% capacity. Despite these discrepancies, DHSR did not enforce corrective action or take steps to close the jail.
Carteret CDF failed every inspection DRNC has on file from 2017-2019 for being overcrowded. According to the LCRs, the jail reported (and DHSR knew) that the facility was rarely in compliance with capacity rules. In 2017, Carteret reported being under capacity for only two days out of the entire year. During those days, they reported being at 99% capacity. During 2018, the jail reported being over capacity every day except for seven days in May, when the jail was between 95% and 100% capacity.
This trend continued in 2019, with the jail reporting being over capacity every day except for 6 days in September when the jail was between 95% and 100% capacity.
Yet Carteret continued to mis-state their population numbers on POCs and in letters to DHSR regarding population reduction. And, although DHSR could have verified the jail’s population numbers using Carteret’s monthly LCRs, they did not. In a letter responding to DHSR’s concerns about overpopulation, the jail wrote that “as of the morning of July 25, 2019 the total in-house population of the Carteret County Detention Center is 125 inmates” while LCRs submitted by the jail show that the population on July 25, 2019 was 143 people, 122% of capacity. In a POC to their July 9, 2019 inspection, Carteret stated that “as of 8/7/2019, the current headcount in the detention center was down to 124” when, according to the LCRs, the jail population on August 7, 2019 was 143 people – 122% of capacity.
On June 12, 2018, Carteret again failed an inspection for being overcrowded. In the POC for that inspection, Carteret stated that “the females should be within designed capacity by 7/31/2018.” But on July 31, 2018, Carteret’s LCR documented the female population was over three times the rated capacity. Based on documents received, it appears that DHSR never checked the accuracy of the statements or promises in Carteret’s POCs nor brought misstatements to Carteret’s attention. Carteret ultimately faced no consequences for these unfulfilled or mis-stated POCs.
Despite chronic overcrowding and multiple failed inspections, DHSR continued to accept POCs from Carteret CDF that repeatedly failed to bring the population to safe levels. DHSR repeatedly accepted POCs that stated the jail was still overcrowded and accepted vague promises from the jail like “[the jail] is hoping to be within our rated capacity within 30 days” and “in the future we will continue to maintain as close to our rated capacity as possible.” None of these POCs were implemented, and Carteret CDF never successfully kept its population down. Despite massive overcrowding since at least 2015 and the failure of every proposed POC to fix the problem, the records DRNC received lack documentation of any attempt by DHHS to take steps to bring the Carteret CDF into compliance.
 DRNC was not given the LCR for January of 2018, and per UNC School of Government documents it does not appear one was filed by the jail.
 DHSR sent a warning to Carteret in July of 2019 to come into compliance with capacity limits or potentially face the beginning of proceedings to force corrective action or close the jail. Carteret sent a POC back stating the facility was not under capacity, but they would try their best to “maintain as close to rated capacity as possible.” DHSR accepted this POC despite continued overcrowding.
Based on LCRs from 2020, 2021, and 2022, Carteret continues to operate at well over capacity. While the population dipped below capacity during the summer of 2020, the facility quickly returned to operating well over capacity. The jail was over capacity for all but 16 days in 2021. Based on a recent inquiry, DHSR allowed Carteret to operate despite being severely overcrowded for the first eight months of 2022, averaging between 130 and 143% of capacity. The severe overcrowding of recent years is particularly troubling given that the updates to the Jail Rules, effective September 2020, require jails to move people out of overcrowded facilities.
Carteret CDF continually operating at over capacity—even after specific changes in the Jail Rules aimed at reducing overcrowding—represents a failure of DHSR to implement the necessary regulations to keep jail staff and people in custody safe.
 Based on monthly averages