A recent prisoner escape from city custody in Virginia was only one of four attempted escapes in the US over 8 days related to seeking medical care. Examining the cause-and-effect relationships shows what led to the prisoner escape and can provide insight into improvements to reduce the risk of it happening again. These cause-and-effect relationships can be diagrammed visually in a root cause analysis, or Cause Map.
The analysis begins by capturing the what, when and where of the problem. In this case, the issue being analyzed is the escape of a prisoner from a public hospital in Alexandria, Virginia March 31, 2015 at about 3:00 a.m. Along with the where, we capture what was happening at the time. In this case, the patient was receiving medical care after a suicide attempt. It’s also helpful to capture any differences. Differences could be in the location, date, time or task being performed. In this case, a few things stand out from a summary reading of the media reports available. First, the city jail prisoner was being treated at a public hospital, and second, one of the guards responsible for the prisoner was taking a bathroom break.
These differences may or may not be causally related to the issue, but provide potential causes to consider. As mentioned, there were four prisoner escapes during a week related to medical care. On the same day, a New Orleans prisoner escaped from a van transporting prisoners to a hospital. The previous day, a New Jersey prisoner escaped from a hospital, and a week prior, a West Virginia psychiatric hospital patient facing murder charges escaped.
As physical and procedural security at prisons improve, fewer prisoners are escaping from the facilities themselves. Many times, being removed for medical care is the best opportunity. Federal prisons, which provide on-site medical care, have far fewer escapes than other facilities. From 1999 to 2001, only one of 115,000 federal prisoners escaped.
A single trip for medical treatment itself may not be to blame for the escape attempts, but repeat trips to the same medical facility may increase the risk. Says Kevin Tamez, inmate advocacy consultant, “Very rarely do these guys go to the hospital for treatment and all of a sudden they decide they’re going to escape. What happens is, traditionally, inmates go to the hospital for treatment . . . they come back to the facility and they start telling other inmates . . . There is nobody more ingenious than an inmate. They have nothing to do all day but sit around and think things up. There are ways of minimizing it, but there’s never a way to prevent it.”
Having only one guard instead of two, due to a bathroom break, is problematic for obvious reasons. It’s far more difficult to overwhelm two guards than one. “From a safety perspective it’s always good to have two people there,” says Gary Klugiewicz, a consultant/ trainer for law enforcement & correctional officers. The amount of time the guards were watching this prisoner at the hospital (4 days, for reasons that are unclear) may have also played an impact. It’s hard to keep your guard up for that amount of time.
The U.S. Marshals, who had responsibility for the prisoner at the time, will be reviewing their procedures to look for opportunities for improvement. Experts suggest that enlisting hospital security to fill in, rather than leaving just one guard in place, may help. Because the secure healthcare facilities in federal jails allow so many fewer escapes, using these instead of public hospitals may reduce the risk of escape. However, there’s still the problem of transporting inmates, which is another high escape potential.
To view the Cause Map of the prisoner’s escape, click on “Download PDF” above. Or click here to learn more.