The state's inspector general for corrections has questioned the lack of a timely response by staff to an inmate's suspicious behavior and a resulting fire May 25 at Tecumseh State Correctional Institution.
Inspector General Doug Koebernick said in a recent written report it was "difficult to believe the appropriate response to an inmate roaming around a gallery for a period of time setting fires is to just let him do that."
The inmate, who was not named in the report, roamed the hallway of a housing unit that evening instead of going to a mini-yard as he was supposed to, passed envelopes from one cell to another and encouraged other inmates to flood the hallway, break sprinkler heads and kick doors.
He then tied bedsheets across the gallery and another inmate helped him to light piles of paper on fire. More than 30 minutes had elapsed from the beginning of the inmate's activity until fire filled the gallery with smoke, and more than an hour passed before he was restrained by staff after he went to an entrance and asked for help.
Koebernick said cameras caught much of the incident.
When the fire started, staff only watched and then attempted to put it out by spraying a fire extinguisher under a door, Koebernick reported.
"The inmates and even staff on the Lower E Gallery were in harm’s way for a considerable amount of time, yet it appears that nothing was done to try to resolve the potentially deadly situation for a period of time," he said.
The prison was less than responsive or timely in addressing the medical needs of the inmates, the inspector general said. Each inmate was escorted out by an extraction team to the medical area, and as a result considerable time passed before some inmates were assessed by the medical staff despite being in a smoke-filled environment.
Department of Correctional Services Director Scott Frakes disagreed with Koebernick's assertion.
"Medical care was provided in a timely manner," he said in a response to the report.
Koebernick said staffing shortages at the prison affected the slower-than-expected staff responses. He reported Frakes said the incident took place on a shift where “staffing levels are lower in the unit” and that this resulted in “slowing the response time.”
There was miscommunication on who was supposed to respond to the incident that also slowed responses, Koebernick said.
Frakes said the claim that the slow response time was caused by low staffing, and that pulling staff from other units created even more shortages in key areas was subjective and not supported by evidence. Miscommunication was the cause for delay.
Koebernick also recommended the department keep all video related to serious incidents for at least 90 days.
He listed these comments and complaints from inmates living on the gallery after the fire: It took seven minutes after staff escorted the inmate out of the gallery before they opened the mini-yard door to let fresh air in. They, too, said there was a significant delay in being seen by medical staff after the fire was extinguished.
It took three days for inmates to get cleaning supplies for their cells, and six days to be allowed to change their bedding, they said. And prisoners received no mental health checks despite the trauma at being locked in their cells with a fire going and thick smoke enveloping them.
Even through it was required, Koebernick could find no record the Tecumseh Fire Department or the State Fire Marshal was contacted, he said. And the Nebraska State Patrol was never contacted about a possible crime of arson.
Warden Brad Hansen told Koebernick in an August email that, “Since there was no damage to the facility, the only person notified as a result of materials lit on fire was the safety and sanitation person...”
Koebernick praised a sergeant he did not name for communicating with the inmate when force was used against him, and when he was placed in a restraint chair. The sergeant was calm and understanding and developed a good rapport with the inmate, which was extremely important under the circumstances, he said.
He also said the Tecumseh staff did an "excellent job of spending time in front of each cell door a number of times communicating with inmates after the fire was extinguished and the first inmate was moved to the medical area."
Frakes told Koebernick in a letter that he agreed every minute counts in an emergency and a timely response is paramount. He agreed with some of Koebernick's findings, but on the recommendation of saving video, he suggested the department could retain video two weeks, rather than 90 days.