Violence, suicides mount in Georgia’s woefully understaffed prisons
Not long after his brother’s murder at Georgia’s Washington State Prison last year, Riheem Jefferson received an Instagram message with a video shot by someone on the inside. It showed four prisoners carrying Marquis Jefferson’s bloodied body, like pallbearers, from a cell to the door of their dorm, trying to get someone’s attention. No guards were around to stop the violence — or even notice that a large, deadly brawl had broken out.
“My brother had no chance,” Riheem said.
On an April night in 2020, Jerry Lackey was in the mental health unit at Augusta State Medical Prison. He was supposed to be checked every 15 minutes. But only one officer was available in that unit, and that officer was needed elsewhere for much of the evening. Early the next morning, when Lackey didn’t take his breakfast tray, he was discovered hanging from a belt.
Anthony Zino was in lockdown at Smith State Prison in April. The guards in the unit were supposed to do counts multiple times each day while providing meals and medications through the flaps in the cell doors. Yet they somehow failed to notice that Zino was dead for five days, allegedly strangled by his cellmate.
Prisons are, by nature, places at risk for violence and self-harm. But the state’s failure to employ enough correctional officers has left Georgia in crisis mode, an Atlanta Journal-Constitution investigation has found. Massive understaffing plagues facilities that house some of the state’s most violent prisoners, and the result can be prisons awash in blood. Gangs are free to carry out increasingly brazen attacks, with beatings and stabbings now routine. Prisoners driven to suicide are left unwatched and able to accomplish their desperate acts.
Over the summer, Georgia Department of Corrections Commissioner Tyrone Oliver said things were going well in the agency he was appointed to lead last December. He acknowledged that a body going unnoticed for five days is a serious issue, but he added it was an isolated incident.
But the AJC’s investigation found that the system is operating at such shocking levels of understaffing it is impossible to keep prisoners and staff safe. As of August, 70% or more of the correctional officer jobs were vacant at eight of the prisons the GDC operates. With so few staff, and with so many prisoners affiliated with gangs, almost anything can happen, especially in prisons overflowing with drugs, cellphones and weapons.
Between 2020 and the end of 2022, at least 90 people were slain in Georgia’s prisons, three times the number from the previous three years. Last year alone, at least 43 state prisoners died by suicide, well above the suicide numbers for any other recent year. And this year is on track to be worse, in terms of violent deaths and suicides, the AJC has found.
The homicides now include a correctional officer, Robert Clark, who was stabbed to death in October at Smith State Prison.
“There are a lot of people in our prison system that are of the most dangerous type of criminal. And we’ve gotten to a point where they are not afraid,” said T. Wright Barksdale, the district attorney for the Ocmulgee Judicial Circuit, which covers three GDC prisons. The prison system, he said, needs to add resources and protocols to control and adequately punish the most violent people and protect both the staff and those who are incarcerated.
The annual turnover rate for correctional officers in Georgia is about 40%. Many who can leave are choosing to get out, some after only months or weeks on the job. Others have been forced out, some because they were caught failing to follow regulations in circumstances caused by dwindling staff.
Charles Powell had worked at Augusta State Medical Prison for seven years when he was fired after failing to monitor Lackey on the night the inmate committed suicide. Powell acknowledges that he didn’t check on Lackey at regular 15-minute intervals. It’s something that torments him to this day. But he said keeping up with frequent checks was difficult for any officer working a unit alone.
“It was basically impossible (to do the job) because of poor staffing,” he told the AJC. “Different emergencies that came up, you couldn’t deal with them when you had one officer instead of three or four.”
Powell said he was always concerned that something catastrophic could occur in the mental health unit at the prison hospital as staffing levels diminished.
“That unit was an accident waiting to happen, and there are other units out there that are accidents waiting to happen, too,” he said.
‘Risks dramatically magnified.’
Finding enough correctional officers has been a struggle for years in Georgia, but the problem intensified when the pandemic hit.
Since 2019, Gov. Brian Kemp has tried to address the issue with pay hikes. The governor has rewarded all state employees with big increases to try to address problems with turnover and vacancies, and he added more for correctional officers. Increases pushed the starting salary for a correctional officer from $31,040 in 2019 to a range of $40,040 to $44,044 today.
The GDC has said it’s working hard on staffing and that things are improving. The correctional officer turnover rate has declined, it said, from nearly 57% in the 2021 fiscal year.
Applications for correctional officer jobs are up, too, according to the department. On social media, the GDC constantly promotes hiring events, highlighting salary levels and benefits. In ads, it refers to the ideals of working in corrections, where officers can “feel valued and trusted” and “positively impact lives.”
In an email, department spokesperson Joan Heath said the GDC has been conducting an average of 160 job fairs a month. Those, along with an aggressive ad campaign, have helped the department hire an average of 125 correctional officers a month over the last six months, she wrote.
Yet, even with better pay, a job monitoring violent and mentally ill people can be a hard sell — particularly when doing it alone.
“When staffing levels get low, the risk to staff, inmates and the public increases,” said Hugh Hurwitz, a prison management consultant and a former acting director of the Federal Bureau of Prisons. “The chance of violence increases, the ability to prevent contraband from entering facilities decreases and the risk of staff burnout increases, further exacerbating the dangers. Corrections staff already deal with more stress and health concerns than other professions and those risks are dramatically magnified as staffing levels decrease.”
Some of Georgia’s most violent state prisons are dealing with staggering numbers of unfilled positions.
As of August, troubled Smith State Prison had just 44 correctional officers on staff to cover all the shifts at a facility housing 1,400 men with high-security needs in 17 housing units. The South Georgia prison is supposed to have 162 officers, according to its staffing records. At Hancock State Prison, another high-security prison housing more than 1,100 men in 16 housing units, just 49 of the prison’s 191 correctional officer slots were filled.
Jose Morales, a retired Georgia prison warden, ended his GDC career leading the Special Management Unit in Jackson, where the state houses its most challenging prisoners. When staffing dropped during the pandemic, Morales said, it was routine to have just five or six officers working a shift that was supposed to have 27.
“We were required to conduct 30-minute checks at a minimum, and if we had anyone on suicide watch, they would have to be checked every 15 minutes,” he said. “When you have a short staff of six people out of a 27-man post, you can’t do it.”
One byproduct of the staffing shortage is a culture in which falsifying documents, particularly count sheets, has become almost routine. In case after case, the AJC found, officers signed off on documents indicating they’d made their required rounds when they had not.
“Pencil whipping” — falsely certifying that checks were done — has become common practice within the GDC. That’s because the agency demands paperwork to show that prisoners have been continually scrutinized, though there simply aren’t enough people to do it, Morales said.
“The paperwork’s gotta be done, and there’s no one to do it,” he said, describing the situation that officers often face. “So it’s all on me. I’m gonna do it the quickest and fastest (way) and I don’t care. You want the paperwork? I’ll give it to you. I’ll sign, sign, sign.”
Impact on health care
The intersection of understaffing and violence has apparently already caused one large shoe to drop: The company contracted to provide health care for Georgia’s more than 40,000 state prisoners — Wellpath, based in Nashville, Tennessee — has decided it can no longer feasibly provide it.
Wellpath, which also has contracts with departments of corrections in multiple states, took over the Georgia contract from Augusta University and its subsidiary, Georgia Correctional HealthCare, in 2021. The contract was due to be annually renewed by mutual agreement through nine years. But in June, Wellpath sent the GDC a notice of nonrenewal, saying the company would pull out of the deal in 2024, seven years early.
Although Wellpath’s letter didn’t state the reasons for the decision, it comes as the company deals with the mounting cost of inmate hospitalizations, as well as growing fears among health care workers that their own safety is in jeopardy.
One of those employees was Mary Rankin, who resigned in October 2022 as the health services administrator at Phillips State Prison, which has about 920 prisoners housed in 10 buildings. Gang violence has been particularly prevalent at the Buford facility, which had more homicides — five — than any other GDC prison in 2022.
“Recently, there has been little to no security staff covering the medical department, and inmate violence against medical staff has increased,” Rankin wrote in a letter of resignation. “I do not feel safe working here.”
Neither Sam Britton, the senior vice president who signed the nonrenewal letter, nor Wellpath’s corporate spokesperson, Teresa Koeberlein, responded to messages seeking comment for this story.
Heath, the GDC spokesperson, said in her email the department has no knowledge that violence played a role in Wellpath’s decision. Instead, she wrote, the company was concerned about “the rising costs of healthcare in general.” She said the department is continuing to negotiate with Wellpath on a new contract.
The staffing shortage also became an issue when Lee Arrendale State Prison, Georgia’s largest facility for women, was subject to accreditation by the Medical Association of Georgia in 2022. Although the organization gave the facility in Habersham County its blessing, it warned that staffing levels had become so problematic that “any significant increase in prison population, decrease in health staff or decrease in correctional officer staffing” could affect future accreditation.
‘No guards anywhere’
The brutality inside Georgia’s prisons exposes how little control correctional officers may have, especially when entire units are staffed by a single guard — if that.
The fight and stabbing that killed Marquis Jefferson at Washington State Prison in May 2022 involved multiple inmates. Two of the attackers were convicted of murder after a trial in Sandersville. Others may eventually be charged.
Riheem Jefferson said he was at home playing Call of Duty one evening when he got a call from the warden, telling him his brother was deceased and he needed to arrange for someone to retrieve the body.
“I said, `What happened?’” Riheem said. “He told me, `All I can tell you is that it was quick.’”
After arranging for his brother’s funeral, Riheem started asking questions. He requested documents and found that Washington State Prison was so understaffed that no one was watching Marquis’ dorm when he was attacked. No one noticed until other inmates carried his body to the door.
Remembering video footage shown at the murder trial, Riheem said, “You see a flood of people going in and beating him. There were no guards anywhere to be seen.”
At Calhoun State Prison, 60-year-old Angel Manuel Ortiz was days away from being paroled in 2019 when he was placed in a holding cell with Frank Hardy, 29, and was mortally wounded. According to a civil suit filed by Ortiz’s family, Hardy had already been moved for being disruptive, and he had threatened to kill anyone placed in a cell with him.
On the day of the attack, prisoners in nearby cells noticed something was wrong, said Robert Leanza Williams Jr., an attorney representing the family.
“They said they heard animal sounds, like an animal screaming, trying to get away,” Williams said. “They couldn’t tell exactly what it was. Then they heard Hardy screaming -- like a wild animal out of his mind.”
Williams, who has obtained sworn testimony through the lawsuit, said those prisoners started banging on cells to get help and screaming for guards, but they got no response. Two female guards who eventually showed up watched the attack from the cell door window instead of immediately intervening, the lawsuit alleges.
Ortiz, who was severely beaten, died after being rushed to a hospital in Macon. Hardy was charged with murder, but a psychiatric evaluation determined he was incompetent to stand trial. He will remain in custody until he’s determined to be competent to stand trial, according to the prosecutor in the case.
Barksdale, the district attorney for the Ocmulgee Judicial Circuit, said his caseload is filled with murders, assaults and contraband cases flowing out of several prisons within his eight-county district. But one case sticks with him: the murder of Bobby Ricks at Hancock State Prison.
Barksdale prosecuted Ricks’ murderers in 2019, and, as the trial opened, he told the jury what happened.
“Bobby was brutally murdered by those that he thought were his friends. His own gang. He was stalked, he was ambushed, he was chased down like an animal and he was stabbed 11 times,” Barksdale said at the trial. “Bobby found himself slipping in his own blood as he attempted to escape his attackers.”
One female guard was covering the dorm of 96 men at the high-security prison. As Ricks tried to flee his attackers — naked, covered in blood, leaving his bloody handprint on a table — the guard did little more than radio for help and watch it play out, according to evidence presented at the trial.
When Barksdale asked the guard during the trial what was going through her mind as she saw Ricks under attack, she responded: “I’ve got to get myself out of here.”
Barksdale told the AJC that prisoners in Georgia are forced to look out for themselves because the staff can’t do much to help them.
If Georgia wants to be tough on crime, it needs to make a dramatic new investment so that the prison system can hire more staff who are better qualified and implement new technology to help, he said. The state also needs to invest in prosecutors in circuits like his, Barksdale said, where they struggle to keep up with all the cases coming out of prisons.
“You’re talking about drugs; you’re talking about gangs. You’re talking about extreme violence. Let’s not forget the sexual assaults that are taking place,” he said. “It is the wild, wild West ... Nobody wants to come in, especially from the top, and say this is out of control. But look at it.”
No checks, no balances
Officers working the isolation and segregation units in Georgia’s prisons are required to check on prisoners every 15 or 30 minutes, depending on the circumstances. They are supposed to note each time they check by signing “seg sheets” attached to clipboards on the cell doors. It’s written right on the forms.
Many of the prisoners in those lockdown units are there because they’ve shown suicidal tendencies or signs of other mental health issues, making the checks necessary. But, as staffing has diminished, officers have frequently been forced to cut corners, sometimes with tragic results.
Lackey, 39, had spent 10 years in prison for an armed robbery in Conyers, a robbery in Winder and an attempted robbery in Monroe when he was found hanging in his cell in the mental health unit at Augusta State Medical Prison. It was early in the morning on April 8, 2020, and the sheet on the door indicated that Powell had looked in every 15 minutes throughout the night. That wasn’t true. Working alone much of that time, he had been pulled away to handle a crisis in another area.
Fired by the GDC for falsifying records, Powell agreed to a lengthy, in-person interview with an investigator from Georgia’s peace officer certification agency. He didn’t mince words.
“I had asked to be moved from (the unit) several times because I knew it was an accident waiting to happen,” he told the investigator. “And I would tell other officers, ‘Working down here is a trap.’ It’s a trap because of the way they staff.”
On top of that, he said, supervisors at the prison hospital left the impression that the door sheets had to be signed every 15 minutes even if officers hadn’t actually been present. The pressure to falsify the forms was subtle but unmistakable, he told the investigator.
“Lieutenants would come by once a night and do rounds, and you might have a unit manager come by and do rounds,” he said. “And if there was nothing on that sheet … then you would be told, `Hey, something’s got to be there.’”
Powell told the investigator he felt deep remorse for what happened and that he had tried to do his job the best he could despite its limitations. “I liked my job, and I thought I was doing something good,” he said.
Lackey’s sister, Cassandra Willis, said neither she nor other members of her family knew the details of Lackey’s suicide until contacted recently by an AJC reporter. Those details, she said, were extremely upsetting. “We are mortified, because this could have been prevented,” she said.
The circumstances surrounding Lackey’s death were much the same as those of an incident at Rutledge State Prison around the same time. In that case, Andrew Campbell, a 28-year-old former Marine who served in Afghanistan and suffered from PTSD, hanged himself just hours after he was placed in segregation because of concerns about his mental health. When Campbell’s body was discovered at 8:40 p.m., the sheet on his cell door had already been initialed to show that he had been seen by an officer at 8:45, 9, 9:15 and 9:30 — an obvious sign that the document had been falsified.
The GDC investigation that followed determined that the only officer present in the unit that night, Antonia Jamerson, had spent much of the evening in the bathroom dealing with a stomach virus and had allowed a cadet to make rounds. The cadet, Warren Baltes, had been on the job only two weeks and had yet to go through the GDC’s basic training course.
The investigator’s notes indicate that video showed Baltes making several trips through the unit but only looking in on Campbell, whose cell was at the end of a hall, once, at 6:31 p.m. Jamerson’s one and only check was at 7:39 p.m., roughly an hour before the ex-Marine’s body was discovered, the notes state.
Jamerson was fired for falsifying documents and other infractions. In a written statement for the peace officer certification agency, he said two officers should have been on duty that night, but “staffing issues” prevented it. He said he allowed Baltes to make rounds so the cadet could “get a feel for the job” and asserted that he was unaware of what was written on the door sheets.
Jamerson expressed remorse, writing that Campbell’s death “haunts me still till this day.”
Contacted recently by the AJC, Jamerson declined to be interviewed, citing the fact that he’s a defendant in a lawsuit stemming from Campbell’s suicide. Baltes, also named as a defendant in that lawsuit, did not respond to messages from the AJC.
‘Left to decompose’
Already reeling from a contraband scandal that has ensnared its former warden, Smith State Prison is also in crisis from understaffing. Seven prisoners have been victims of homicides there this year, the most of any GDC facility, and one — Zino — presents perhaps the most gruesome picture of the inadequate staffing.
The cause of Zino’s death has been listed as asphyxia due to neck compression. His cellmate, Tommy Pickren, has been charged with felony murder in what the GDC has described as a “mercy killing.” But the department has yet to explain how the 71-year-old inmate, serving life without parole for killing his wife and teenage daughter in their Cobb County home in 1999, lay dead inside a mattress for five days before anyone noticed.
“The saddest thing is he was left to decompose and become less of a physical human being,” Zino’s sister, Barbara Chadwick, said, speaking publicly for the first time. “He made a terrible, terrible mistake. But that doesn’t mean there weren’t people who loved him. The fact that he was left to rot like a piece of meat is disgraceful.”
Zino is buried in the Georgia state prison cemetery in Reidsville, another cross with a number and no name in a field of them stretching to the horizon.
Zino’s death remains the subject of an administrative investigation focusing on policy and procedural breakdowns, Heath said. She did not provide details except to assert that “understaffing did not play a role in this incident.” In response to an open records request from the AJC, the department declined to provide documents stemming from the inquiry, saying they were protected from disclosure as “confidential state secrets.”
Zino wasn’t known to have any major health problems. But apparently, life at Smith State Prison weighed heavily on his mind. Just days before his killing, he wrote a short letter to a friend stating that “certain things have happened here at Smith, and I have things I have to sort thru and deal with.” He did not elaborate.
When the AJC interviewed the GDC commissioner in July, Oliver insisted Smith State Prison had “turned a corner” under the leadership of Jacob Beasley, who became warden in February, after Brian Adams was charged with violating the state Racketeer Influenced and Corrupt Organizations Act for his role in an inmate-run contraband smuggling scheme. Heath made a similar claim in her email, noting that Beasley has been cracking down on contraband, implementing discipline within the facility and taking other steps that have brought “significant improvements in inmate behavior.”
Facts say otherwise. Since February, records show Tattnall County EMS has been called to the prison in Glennville to transport 66 prisoners for assaults, mostly stabbings. All told, the county’s EMS personnel have been called to transport 173 prisoners for assaults since the beginning of 2020.
In mid-June, an officer at Smith, Douglas Bare, walked off the job after nine years. When contacted by the AJC, he said he had grown weary of working in such a dangerous environment as well as being repeatedly pulled from his post to make hospital runs.
Asked to describe the underlying problem, he was succinct: “Chronic understaffing. There just weren’t enough people to go around.”
Less than four months later, Clark, the correctional officer working at Smith, died from injuries he suffered when he was stabbed from behind by a prisoner he was escorting from the dining hall. The 42-year-old officer had been employed by the GDC for only five months, having previously worked at Walmart.
Clark’s mother, Elizabeth Connolly, said her son struggled to keep up with the demands of the job because it wasn’t unusual for one person to guard three buildings on a shift, especially if someone had called out or an officer had to take somebody to the hospital.
She said a lot of questions remain about what went wrong the night her son was killed, but one thing is clear: Smith State Prison was severely understaffed.
“It’s no secret,” she said. “Everybody knew.”
About This Investigation
This is the latest installment of an Atlanta Journal-Constitution investigation into the extensive problems in the Georgia prison system. AJC reporters found that the system is setting grim new records for homicides and suicides. Documents about those deaths and other violence raised troubling questions about how correctional officers responded and whether staffing in the state’s prisons is sufficient to protect employees and prisoners.
This installment is based on staffing documents, incident reports and other information obtained from the Georgia Department of Corrections; documents compiled by the state’s peace officer certification agency; court records; medical examiner findings; and emergency medical service data. Reporters also reviewed dozens of videos recorded by prisoners and interviewed family members and attorneys of inmates who died, former GDC employees, Georgia prosecutors and experts on prison management. The data reporters gathered was provided to the GDC in advance of publication, so it could verify or challenge the findings. The AJC also provided GDC officials with a list of questions and received an emailed statement that did not address all the specific questions the newspaper had asked. GDC Commissioner Tyrone Oliver sat down for an interview with the AJC in July.
The first installment of this investigation, published in September, revealed extensive corruption by Georgia prison employees and its role in triggering violence. In October, the AJC’s second installment revealed how fatal drug overdoses have dramatically increased in Georgia prisons.