Report faults Scott County Jail for ignoring inmate’s mental health crisis

Scott County Jail workers allowed a woman in mental distress to repeatedly bang her head against cell walls for hours without intervening or providing medical attention, a new report from the Iowa Office of Ombudsman alleges.

The woman, identified in the report only as “Sarah,” was arrested with her husband after a domestic incident on Christmas Eve, 2024. According to the ombudsman’s report, she was not given the chance to disclose her mental health history upon admission to the jail and was accused of trying to manipulate officers when she wrapped a phone cord around her neck.

The report states Sarah was largely ignored by the jail staff as she rammed her head, face and body against the hard surfaces of her cell throughout the evening.

According to the report, video recordings show Sarah vomiting on a few occasions while displaying signs of disorientation. At one point, she appears to pass out against a cell door. In their records, officers wrote that they checked on Sarah every 15 minutes, but the jail surveillance footage does not support that claim, the ombudsman found.

Although the jail’s own policy, as well as national jail standards, call for continuous observation of suicidal inmates pending a visit from mental health staff, the Scott County Jail officers never alerted mental health staff to the woman’s distress, nor did they consider placing her in a restraint chair to protect her from injury, the report noted.

“When the woman was released from jail the next morning, her right eye was completely swollen shut, while the rest of her face and arms showed multiple bruises and cuts,” the ombudsman’s office reported. “She told us she had suffered a concussion at the jail and was still receiving treatment a month and a half later.”

“No person in custody should have to suffer through a mental health crisis without medical attention and observation by officers who are obligated to keep them safe,” Ombudsman Bernardo Granwehr said in a press release accompanying the report. “Every jail administrator in Iowa should use this report to re-evaluate their own policies and practices to ensure this doesn’t happen in their facilities.”

Among the report’s key findings and conclusions:

Excessive delay in booking: Sarah was not fully booked into the jail until 19 hours had passed after her arrival. The delay likely prevented the jail staff from identifying her mental health risks.

Staff minimization of a mental health crisis: Body camera footage captured the staff making insensitive, dismissive remarks about Sarah’s pain, injuries and suicide attempt —suggesting she was “faking it” or trying to “go to the hospital.” The comments, the ombudsman found, “reflect poor training and judgment and contributed to a failure to appropriately respond to her crisis.”

Lack of wellness checks: Although jail logs indicated the staff checked on Sarah every 15 minutes, video showed that in-person or meaningful observations did not occur, and staff “did not intervene despite hours of violent self-harm visible on camera,” the ombudsman reported. Sarah should have been under continuous observation based on jail policy and state law, the report states.

Failure to protect: Sarah repeatedly struck her head on cell doors, walls, and the floor, pulled out her hair and vomited, and lost balance and consciousness — all with little to no response from the jail staff.

Lack of mental health services: No medical or mental health providers evaluated Sarah during her crisis, and the jail lacked available mental health services during holidays.

Lack of reporting: The jail failed to report Sarah’s suicide attempt and self-harming incidents to the state jail inspector within 24 hours, as it was required to do.

The new report commends Scott County jail officials for their response to the ombudsman’s investigation and for admitting lapses in judgment by their officers. The jail quickly initiated changes to its policies and practices in the wake of the incident, the report states.

Editor’s note: Reporter Clark Kauffman worked for the Iowa Office of Ombudsman from October 2018 through November 2019.