WILMINGTON — An independent review of the February inmate uprising at James T. Vaughn Correctional Center that left Lt. Steven Floyd dead concludes the riot may never have happened if a request by the slain correctional officer to transfer “over five” inmates hadn’t been ignored.

The results of the monthslong review of February’s uprising was released on Friday.

The review states:

“The incident that began on Feb. 1, would have likely occurred at some point somewhere within the JTVCC.

“However, the mix of inmates flowing down from maximum to medium security and inmates flowing up from medium towards maximum security in the C-Building and the circumstances giving rise to that mix, as more specifically set forth in the body of the report, hastened the inevitable.

“Most unfortunately, the Independent Review Team believes that had the request for the removal of certain inmates from the C-Building made on Jan. 20 by the very correctional officer who was killed during the incident that began on Feb. 1, been taken more seriously and carried out, the incident and the resulting death may not have occurred.”

The review, requested by Gov. John Carney and conducted by a former Family Court judge William Chapman, Jr. and former U.S. attorney Charles Oberly III, centered on the conditions at the prison leading up to the incident in which inmates took several correctional officers hostage.

A 19-hour standoff followed, and Lt. Floyd was found dead after authorities breached Building C, the site of the uprising, early Feb. 2.

The independent review team conducted interviews with correctional, educational, mental health and medical staff, including correctional supervisors, JTVCC administrators and Delaware Department of Correction (DOC) executive administrators past and present.

The team also reviewed numerous letters from inmates and family members, spoke with community and inmates’ rights groups and interviewed other agency representatives to put together a 159-page final report.

The report makes recommendations to the governor and legislators on how to avoid a similar incident while addressing the “systemic” ills of the DOC.

The final report expanded on many of the same issues cited by a preliminary report published in June. Those issues included communication problems between management and staff, low morale and fatigue among correctional officers, chronic correctional officer under-staffing and a lack of focus on rehabilitating prisoners.

The review states:

“Conditions at the JTVCC had deteriorated to the point that there was unrest among inmates, and distrust between inmates and correctional officers, as well as between correctional officers and JTVCC administrators.

“Factors giving rise to this unrest included adverse working conditions for the correctional officers, who continue to feel unappreciated by the administration, inconsistently implemented rules and regulations, an inmate grievance procedure deemed unfair, a distrusted medical/mental health system and a real lack of morale permeating the line officers.”

Gov. Carney thanked Mr. Chapman and Mr. Oberly for their efforts and renewed his pledge to aggressively pursue the review’s recommendations at a press conference held in Wilmington.

“We had an interim report in June that allowed us to go to the legislature and seek funding for some of the improvements that were recommended in the report,” said the governor. “We are actively pursuing those through the Department of Corrections and with special assistant Claire DeMatteis who is driving those changes.”

Ms. Dematteis, a Delaware lawyer, was appointed in June. Gov. Carney also mentioned his administration had reached an agreement with the Correctional Officers Association of Delaware to increase pay for officers across experience levels. That includes a 22-percent increase in starting officer pay that they claim will help the state recruit and retain officers across the correctional system.

The starting salary, increased this financial year to $40,000, is set to increase again in fiscal year 2019 to $43,000.

Other changes made by the current administration include the creation of a new Labor-Management committee to study ways to help recruit and retain officers; decrease the use of mandatory overtime; a $1.3 million investment in new equipment to help officers more safely respond to violent incidents; and a $2 million investment in new cameras purchased for JTVCC.

“In an incident like that, we didn’t have cameras to be able to see inside what was going on — that’s just an unacceptable situation,” Gov. Carney said.

However, the point driven home the hardest by the review remains the chronic under-staffing of correctional officers. According to the DOC there are currently 264 vacancies for the position.

“Staffing has to be number one,” said the governor. “We’re working on that. We have a new contract and we’re bringing a larger pool of applicants to the vacancies we have. We’ve had some success getting applicants to that pool, but we’ve also had people wash out, too.”

Geoff Klopp, president of the Correctional Officers Association of Delaware (COAD), said the salary increases don’t go far enough to address the understaffing.

“We got an up-tick in applications after the salary increase, but we’re still ending up with the same amount of qualified people,” he said. “We had close to 400 applications in August, but we’re only going to hire 40 new officers out of the academy between now and Christmas.”

The high rate at which the DOC is losing officers stacked against the slow rate of replacement is setting the stage for another tragic incident, Mr. Klopp said.

“The DOC just says there are 270 vacancies, but it’s incorrect based on the amount of overtime we work on a weekly basis,” he added. “We’re working between 13,000 and 15,000 hours of overtime per week across the state — so we estimate the actual number of vacancies to be closer to 400.

“Forty new recruits in the academy is nowhere near enough. Right now we’re losing between 10 and 12 COs per month. You do the math.”

Mr. Klopp, although “frustrated” with Gov. Carney not acknowledging the COAD’s original suggestion to raise starting salaries to $47,000, looks forward to pushing ahead with the governor and attempting to resolve the shortage.

He’s much less satisfied with the General Assembly’s performance, though.

“I look forward to continuing to work with Gov. Carney. I just wish we would have attacked the issue more aggressively,” he said. “I was never happy with the increase to $40,000, but we had no choice really. The General Assembly, on the other hand, has been nonexistent in helping the correctional officers, and they’ve known about these issues far longer than Gov. Carney. They’ve done nothing.

“We didn’t just start talking about this in February, I’ve been talking about this for over three years now.”

Mr. Klopp said the independent review is largely a rehash of the one delivered to former Gov. Ruth Ann Minner after a hostage incident at JTVCC in 2005. He agrees with the majority of the recommendations but speculates that the administration won’t be able to act on them until the staffing shortage is addressed.

Both the criminal and internal affairs investigations into the Feb. 1 incident are ongoing. Earlier this month, the state Attorney General’s Office announced that a grand jury indictment related to the uprising was expected in 90 days.