CLEVELAND, Ohio — The overwhelming question arising from Wednesday’s release of an exhaustive U.S. Marshal’s Service report about inhumane conditions at the Cuyahoga County jail is this:

How did things get so bad?

The answer, according to a two-month cleveland.com investigation, is money.

While crowding overwhelmed the understaffed jail, while conditions throughout the facility worsened – while seven inmates died in four months -- the chief conversation by county officials about the jail was about how much revenue could result from a game-changing consolidation of jails throughout the county.

The deaths, between June 10 and Oct. 2, happened as Cuyahoga County Executive Armond Budish commenced his long planned merging of many city and township jails – including Cleveland’s -- into the system operated by the county. At every juncture of the planning, the chief benefit discussed was money – how much savings the cooperating cities would realize, and how much revenue the county could generate for itself.

Last year, Budish said that jail regionalization would bring in $5.5 million to the county over two years. Maggie Keenan, county director of the Office of Budget and Management administration, said at an April 3 committee meeting that more money could be brought in if the county continued to add more inmates.

If more than half of the jail’s beds were filled as a result of taking on regional inmates, the county would “break even,” Keenan said.

But money raised beyond that break-even point by filling more beds would then be used to shore up the county budget. That would happen by using the extra revenue to pay jail expenses, including administrator salaries, that for years have been paid from county taxes, county spokeswoman Mary Louise Madigan said after weeks of questioning by cleveland.com.

To understand the breadth of the issues involving the jail, cleveland.com spent months conducting dozens of interviews of current and former corrections officers, inmates, medical staff and other employees, and reviewing several lawsuits, the county’s own budget projections and public records. The sources agreed to speak with cleveland.com under the condition of anonymity because they fear retaliation. They attributed that decision to the ousting of Gary Brack, a former medical supervisor at the jail who was forced out after speaking critically of now-former jail director Ken Mills during a County Council committee meeting.

Regionalization and revenue

The drumbeat of talks over regionalizing the county jail system have been persistent since the days of the county commissioner form of government, which ended in 2010. The talks began in earnest with the first county executive, Ed FitzGerald, who reached a tentative deal with the city that he did not complete before leaving office.

Budish made jail consolidation a top priority when he took office in 2015. And when he went out to sell it, he talked about the money. The county sold the idea to cities and townships as a way for them to save money and “get out of the jail business,” which is often one of the costliest and most difficult local government functions.

County officials argued that they were the authority on running a jail anyway, since they are one of the largest jails in the state.

Fitzgerald created a new position, director of regional corrections, specifically to shepherd regionalization throughout the county, but never filled it. Budish hired Mills, who did not require confirmation from the County Council, despite his lack of experience working in or running jails. He was the only person considered for the job.

Mills was persuasive.

Cleveland signed on. The county cut deals with Euclid, Bedford Heights, Woodmere, Bratenahl, Richmond Heights, Highland Hills and Moreland Hills. As many as 16 other Cuyahoga County communities told the county that they are be interested in signing over their prisoners, Mills told council members earlier this year.

Not part of the sales pitch to the cities was the benefit to the county’s coffers of consolidation. Bringing inmates from cities and townships under the county umbrella – and charging them $99 per day per inmate -- would grow the county’s revenues.

County officials said in various public meetings in late 2017 and early 2018 that they expected net revenue from jail regionalization to be between $1.7 million and $5.5 million per year.

“As long as we keep the beds filled up, I think it’s a very safe projection,” Mills told County Council on April 3.

At the same time, records show the county spent less money on basic supplies for inmates, such as toilet paper, under Mills’ direction. They reduced the cost of inmate meals. Mills also sought to cut costs by switching the jail’s providers of food and medical care.

Last fall, Budish proposed the regionalization plan as a way to help close a gap in the budget, primarily triggered by the loss of $60 million in state money.

More than a year later, Keenan backtracked, saying the jail revenue proposal was mistakenly included in a list of ways to address that budget shortfall, and that all money from the jail would be used on jail expenses or expansion. But because county taxes were subsidizing the jail, getting revenue from consolidation to pay jail expenses could free up tax money for other uses.

The consolidation had startup costs. The $99 per-day rate paid by Cleveland and others was to be used, in part, to pay for jail expansion, but that expansion would be paid off in the first two years. After that, the county would have extra money to put back into the general fund.

Under questioning by cleveland.com about the county using the jail to generate revenue, Keenan said something Monday that she had never said before: The actual per-diem cost could drop after the startup costs were covered. If that happened, Keenan said the county would charge Cleveland, or any other municipality, less money per inmate.

That has never before been publicly discussed and it was not mentioned when Cleveland first announced the deal, which allows the county to increase the per-diem rate by 2 percent annually.

County officials say they plan to reinvest all additional revenue made from regionalization into jail operations and expansion. Again, though, because the county uses tax dollars to pay for much of the jail operations, any revenue from consolidation used for jail operations would free up tax dollars now spent on the jail to be used elsewhere.

Meanwhile, conditions at the jail get worse, and inmates start dying

During all of the selling and planning for consolidation, conditions were getting worse in the downtown jail, as the marshal’s investigation ultimately showed. The county absorbed the Cleveland prisoners over the summer and negotiated with small police departments for handling their prisoners.

Inmates started dying in June, but the revenue-generating plans for consolidation continued. Finally, after the seventh death, Budish put regionalization on hold.

“Because it doesn’t make sense to add more prisoners if we can’t handle them,” Budish told cleveland.com.

When did the project go so far off the rails?

The influx of Cleveland’s 160 inmates clearly overwhelmed a county system that already was over capacity. Mills had told County Council members that he expected a smooth transition of adding Cleveland inmates to the jail and only foresaw “paperwork issues.”

Paperwork issues did arise, and they led to inmates being jailed for several days without seeing a judge or being formally charged with a crime. In one case, a man with a simple traffic ticket spent six days in jail before seeing a judge. Several others were held for more than five days without seeing a judge or without being charged with a crime, the records show.

But paperwork issues don’t result in deaths. The crowding and inhumane conditions were the likely culprits for that, and the marshal’s report says 55 inmates tried to kill themselves in a single year.

Mistreatment of inmates included:

· Locking them down for 27 hours at a time, because the jail was too understaffed to monitor them in dayrooms

· Forcing some 100 inmates to sleep on mattresses on the floor every night

· Jail officials, including the warden, withheld food as punishment

· Pregnant inmates were seen sleeping on the floors

· A specialized squad of paramilitary officers known as the “Men in Black” routinely intimidated and harassed inmates

· Inmates were denied access to running water and toilets for hours at a time

· Vermin and mice infested food storage areas

· Inmates with mental illnesses were placed in isolation and denied access to mental health care for the duration of their stay

· Child inmates are housed with adults, and are subjected to the same lockdowns

And the list goes on.

Budish said he had no idea conditions were so bad until receiving the marshal’s report. He said he requested the marshal’s investigation because he was shocked by the seven deaths.

Cleveland.com asked Budish whether he asked questions about whether the jail had the resources to absorb so many prisoners, feed them, see to their medical needs and keep them safe. He said he relied on state inspection reports that gave the jail good reviews as proof that the jail had the capacity.

Consider the contrast. When it came to the money, Budish has for months been able to speak with specifics about the costs and the revenues. When it came to the mechanics, his answer almost always came back to state inspection reports.

The Ohio Department of Rehabilitation and Correction inspected the jail twice since June, a criminal investigation is underway in connection with the death of one of the inmates and the FBI is investigating a use-of-force involving an inmate and a corrections officer.

The state inspections overlooked many of the more “inhumane” aspects of the U.S. Marshals’ examination of the jail, Budish and the sheriff both noted that jail officials are given significant notice ahead of state inspections.

U.S. Marshal Pete Elliott, who organized the investigation, explained why the state and federal investigations reached different conclusions.

“At the end of the day this is the difference: If a father thinks something’s wrong with his son, goes and walks around his bedroom, walks out and thinks everything’s okay. Then the mother goes up to the bedroom, looks in the dresser, looks under the bed, looks under the curtains and finds things,” Elliott said. “That’s the difference. That’s what the federal part is. They looked behind the curtains when they saw curtains. And across the board, they found it to be unsatisfactory.”

However, a consistent concern of state investigators was always the population of the jail, and Budish and his jail administrators continued to court inmates for a jail they knew was already crowded.

In earlier discussions with cleveland.com, both Mills and Budish discussed something called “red-zoning,” which is a practice in understaffed jails where a single corrections officer oversees between 100 to 200 inmates spread across two to four hosing areas called pods. It often resulted in large groups of inmates placed on lockdown for hours with little to pass the time. The marshals’ report showed that some lockdowns went on for up to 27 consecutive hours, or the same inmates were locked down for 12 days in a row.

Sources and documents obtained by cleveland.com showed that red-zoning leads to corrections officers being overwhelmed with routine tasks, responding to individual inmate needs and questions, helping to distribute food and medicine, and checking on inmates every 15 minutes, as county policy requires.

As the jail population continued its rise, so did the frequency of red-zoning and locking inmates down for most of the day.

Mills said in October that jail supervisors try to plan out daily staffing so the same inmates aren’t locked down for two days in a row. He acknowledged, however, that’s not always possible.

“You try everything you can to keep someone from being on lockdown two days in a row,” Mills said. “But sometimes it’s staffing. It’s what happens.”

Staff shortages

There were 553 corrections officers at the downtown jail at the time of the most recent death, 60 below what the jail needs to meet national jail staffing standards.

Budish said in October that he authorized the county to hire those additional officers, but acknowledged that if everything goes according to plan, it would take until spring of 2019 at the earliest to train and hire them all.

The lockdowns and high population create tension among the corrections officers, sources said.

Budish and Mills both blamed the problems on corrections officers calling off work. The union that represents the corrections officers also acknowledge the call-offs are an issue. The two sides are at odds as to why.

The union says that the conditions at the jail are so bad the officers get burned out. They say officers must watch multiple pods at the same time, and that supervisors require them to work four hours of overtime at the end of their shift when someone else calls off. The officers who are forced to stay the extra time get more burned out and end up calling off sick, forcing another corrections officer to work overtime in a cycle that seemingly has no end.

Mills said the county has tried to aggressively hire new corrections officers for years, and Budish said that the staff level increased under Mills. But they’ve only raised their staffing level by about 10 officers during Mills’ tenure, Budish said in October, and there was a mass exodus of officers retiring or resigning in 2017.

Budish, along with the Ohio Police Benevolent Association, the union that represents corrections officers, said they’ve struggled to get candidates to apply, and the ones who do don’t always make it through training and their probationary term. The county also expected to hire 60 Cleveland City Jail officers after the transition, but only got 30.

The officers are hired at $15.31 per hour.

Mills said they planned on offering jobs to 35 candidates after they pass their corrections training program at Cuyahoga Community College this month. He said new hires will be used to help reduce daytime lockdowns.

Even if the jail was at full staff, however, current corrections officers say tensions with the administration are constant and hamper their ability to do their jobs. Several said they worry about the well-being of inmates and themselves and have tried to bring safety concerns to the attention of administrators, but those concerns are routinely ignored. The OPBA in 2017 offered to pay for an independent review of the jail’s policies and procedures, but the county denied the request, OPBA Attorney Dan Leffler said. A county spokeswoman did not respond to questions about why the county declined the union’s offer.

Budish acknowledged Wednesday that there are entrenched problems within the jail administration, and, in the same meeting, Cuyahoga County Sheriff Clifford Pickney said that more jail administrators could head to the chopping block -- including current warden Eric Ivey – in order to win back the confidence of the corrections staff.

The directors of the union have filed several grievances against the county regarding several issues around overcrowding, double-podding and officer safety. In many cases, those grievances receive blanket denials, the union said, meaning problems aren’t fixed in the short-term and can often drag out for months.

The union in August filed an Unfair Labor Practices charge against the county about those blanket denials. The two sides met Oct. 11 with a State Employee Relations Board mediator. A ruling has not yet been made.

What’s the county going to do about it?

Budish pointed out that the jail administration does not choose how many inmates are sent to the jail or for what crimes, but he continues to acknowledge the jail’s problem with overpopulation. But without a steady stream of money, Budish’s financial plans for his regionalized jail system fall apart.

There are two major hurdles to fixing problems in the jail, Budish said. Both are long-term, systemic changes that will require money, time and collaboration. This became more apparent Wednesday as Budish and Pinkney continued to grapple with the magnitude of the findings contained in the marshals' report.

Budish has previously pointed to bail reform efforts as one way to reduce low-level crime suspects in jail. But Budish said he can’t implement those reforms on his own.

“You have to have the agreements between the municipal judges and the common pleas judges,” Budish said. “No one can just mandate that this comes together.”

The second long-term solution is the need for a new Justice Center. Budish and Mills said the jail's outdated physical structure makes it difficult to monitor inmates efficiently.

A decision about whether to remodel the current jail or build a new one was expected by the end of 2018, but that process has been delayed because Budish and the judges have yet to reach an agreement on specifics of the plan. However, the marshals’ report underscored a number of urgent potential civil rights issues that the county won’t have the luxury to address when it has the resolve or extra cash on hand.

Other measures being proposed to reduce population include implementing a mental health diversion program, re-entry programs, and additional use of GPS tracking in lieu of jailing.

Two other programs aimed at reducing jail population are also being developed in conjunction with the courts, but those are months or years away from implementation.

The problems within the jail prompted all 34 Cuyahoga County Common Pleas judges to say they no longer trust the jail administrators’ assurances that they will fix the problems. They accused Budish’s administration of indifference. A Cleveland judge also made national headlines when he said he would no longer send non-violent offenders to the jail for fear they’d end up dead.

The county promised in a press release to open the Bedford Heights Jail at least one month before it started accepting city inmates. They were moved into the county jail this summer, but by October, Bedford Heights Jail could only accommodate 60 people — not the 200 it is expected to hold.

Budish said in October that once Bedford Heights Jail is operating at that full capacity, it will help alleviate the crowding at the downtown jail. County officials said they never intended to fill the Bedford Heights facility to capacity after it first opened, and that a lack of corrections officers and nurses contributed to a delay in moving inmates out of the downtown jail.

Other plans to reduce overpopulation in the downtown jail included renovating an old kitchen into housing at the downtown jail and bringing the Euclid jail up to capacity — it can hold 83 people, but only about 45 were being held there in October. Mills and Budish told cleveland.com that once Euclid and Bedford Heights are up to capacity and the downtown jail is expanded, there will be 350 more beds for inmates.

Those projects weren’t complete before the county opened the doors of the downtown jail to inmates from the city.

And even if the plans for expansion in Bedford Heights and at the downtown jail went through, the downtown jail would still be over capacity by about 100 to 350 inmates, depending on the day.