According to the preliminary report, prison workers consider communication to be the top problem at James T. Vaughn Correctional Center.
The report released Friday portrays stressed-out correctional officers as not knowing what is expected of them, a disconnect between shift supervisors and upper management, and confusion and anxiety among inmates who have no certainty about how they will be treated.
"The lack of consistent operations as well as the inconsistent administration of policies and procedures were identified as significant areas of concern by staff and inmates," the report states.
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The review also confirmed what prison workers have said previously but Department of Correction officials have refused to publicly acknowledge: There are no surveillance cameras inside the building where the February uprising occurred.
"While cameras may not have prevented the incident from occurring, they could have had a deterrent effect and could have provided additional information for post incident investigations had they been installed inside the housing unit," investigators wrote.
Although it's unclear whether gang members were involved in the riot, staff told investigators that gang members were housed not only in the same cells in C Building, but also in adjacent cells and across the hall from one another, "making communication and planning much easier."
"This situation was compounded by the fact that since October, all three tiers of C-Building were in the yard for recreation together," investigators wrote.
Reviewers also noted that the building was originally designed to house maximum-security inmates but now houses medium-security inmates, who have more freedom of movement.
"In C-Building, inmates were allowed to occupy areas of the housing unit that were difficult for staff to safely observe and control because of the building's design," reviewers noted.
Delaware State Police still are conducting a criminal investigation into the uprising, during which inmates took four prison workers hostage, setting off a nearly 20-hour standoff during which correctional officer Steven Floyd was killed. The siege ended when tactical teams used a backhoe to breach the building and rescue a female counselor. Two other guards had been released earlier after being tormented and beaten by inmates.
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In ordering a separate, independent review of security issues at Vaughn, Democratic Gov. John Carney had planned to wait until the criminal investigation was completed. He later changed his mind and ordered a preliminary report by June 1, allowing lawmakers to consider possible legislation to address prison issues before they adjourn the current legislative session July 1.
The independent review found that the confusion that defines operations at Vaughn extended to the emergency response itself during the Feb. 1-2 uprising, with three separate command posts established.
One post, inside the prison, was led by the warden, who under DOC policy is the "ultimate commander" in the event of a major emergency and is in charge until the situation is resolved.
But DOC leaders, along with officials from the Department of Safety and Homeland Security and Delaware State Police, gathered at a separate command post at DOC headquarters in Dover. State police also set up a mobile command post outside the prison, where they were joined by FBI officials. Disparate radio frequencies used by various agencies complicated the situation, investigators found.
One example of the confusion caused by the three command posts involved a request by state police for Wilmington police to deploy a drone to monitor the building where inmates had seized hostages.
"The warden was unaware that it had been requested by the outside command post and at first threatened to shoot it down because he thought it was a news media drone," investigators wrote.
The reviewers, led by former Family Court Judge William Chapman and former Attorney General and U.S. Attorney Charles Oberly III, submitted a list of 30 recommendations. The recommendations include developing a strategic plan and implementation process for the Department of Correction, improving communication, training and information sharing, and decreasing the inmate population or encouraging alternatives to incarceration.
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