Thirty-year-old Jessica Fortson was serving a one-month stint in solitary confinement at the Women’s Community Correctional Center in Kailua when she decided to hang herself using a bedsheet.

Found unconscious in her cell by prison staff, the mother of two died an hour later after medical personnel were unable to revive her.

It wasn’t the first time she had tried to kill herself while serving a five-year sentence on nonviolent offenses, raising concerns about the safety of placing her in solitary confinement. Her father told the Honolulu Star-Advertiser last year that his daughter suffered from bipolar disorder.

Fifteen months later, there are still no public answers as to whether prison staff followed internal policies aimed at preventing suicides or whether any reforms were put in place to prevent similar tragedies. The Hawaii Department of Public Safety won’t release the results of its internal investigation into Fortson’s July 2017 death, nor will it release information on the 25 other inmates who committed suicide in Hawaii jails and prisons since 2010.

Hawaii’s inmate suicide rate is the seventh highest in the country, according to Bureau of Justice statistics.

The lack of public information about inmate suicides is just one reason a 13-member task force chaired by Hawaii Supreme Court Associate Justice Michael Wilson is recommending the state create an independent oversight commission to inspect and monitor correctional facilities, investigate complaints, report findings to the public and shepherd in broad reforms to Hawaii’s prison system.

“The public never finds out anything,” said Robert Merce, an attorney and member of the task force. “All the public knows is that people are killing themselves in this prison system at an alarming rate. That is why you need an independent, outside agency to go in immediately and investigate all those kinds of things and find out what are the policies, are people following the policies or are the policies themselves the problem.

“Obviously there are a lot of things going on that need to come to light and you need to expose them, you need to disinfect them with sunshine and let the people know that these problems, we are going to take care of them.”

The task force report, which is expected to be finalized and submitted to the Legislature by the end of the year, cites other recent incidents in support of its recommendation for an independent oversight commission.

Federal lawsuit

Several months before Fortson’s death at WCCC, 10 women at the prison filed a federal lawsuit alleging they were sexually coerced, assaulted or raped by guards. According to the lawsuit, which is pending, some women were given crystal methamphetamine, food, makeup and special privileges in exchange for sexual favors.

The lawsuit alleges an ongoing pattern of sexual abuse at the women’s prison dating back at least 25 years.

There continue to be dozens of reports of sexual assaults at Hawaii correctional facilities. In 2015, there were 31 reports of corrections officers sexually abusing inmates, eight of which were substantiated. That same year, there were 33 reports of sexual assaults of inmates by other inmates, four of which were substantiated.

In September 2017, three guards at the Oahu Community Correctional Center, the state’s largest jail, were attacked by 18 inmates upset about long periods of lockdown because of staff shortages.

In January 2017, following years of severe overcrowding at correctional facilities, the American Civil Liberties Union of Hawaii filed a complaint with the U.S. Department of Justice alleging conditions in Hawaii’s jails and prisons violate constitutional protections against “cruel and unusual punishment.” The report detailed severe understaffing of medical and mental health services, unsafe food practices, unsanitary conditions and aging infrastructure.

An independent commission “is something that is much needed in Hawaii because our prisons and jails are black boxes and the Department of Public Safety is very, very bad at both compiling and also providing the public with information,” said ACLU Hawaii Legal Director Mateo Caballero.

The Department of Public Safety didn’t respond to several requests for interviews with Director Nolan Espinda on whether an independent, oversight commission could help address problems at prison facilities.

DPS spokeswoman Toni Schwartz said in an email statement the department is “an active participant” in the panel’s discussions and that “this administration will apply full consideration to the recommendations made in the task force’s final report and will continue to work with them and the Legislature.”

Inmate complaints

There is no independent entity dedicated to investigating inmate complaints. Instead, any such grievances are handled by the Office of the Ombudsman, which handles complaints relating to nearly all state and county agencies.

With a staff of eight, the Office of the Ombudsman generally only responds to complaints rather than fully investigating them and operates largely in secrecy.

In fiscal year 2016, the ombudsman received 1,706 complaints against DPS, which represented 63 percent of its total caseload that year. Only 4 percent of complaints related to the Department of Public Safety were substantiated.

The Department of Public Safety does have internal affairs and investigation divisions to look into suicides and other cases. There is also an internal grievance process for inmates to file complaints. Sometimes, the ombudsman will ask that they go through this process first.

While the Office of the Ombudsman releases short summaries of a handful of investigated complaints in its annual reports, all other information is kept strictly confidential. Ombudsman Robin Matsunaga said by statute his office is required to maintain secrecy and that releasing more information could have a chilling effect on people disclosing information to the agency.

The task force envisions a much more robust oversight commission that would not only respond to inmate complaints but conduct unannounced inspections of correctional facilities, interview corrections staff and inmates, help ensure broader reforms are implemented, including bail reform and transitioning to a rehabilitation-focused corrections model, and report regularly to the public.

“To me, one of the absolute critical parts of having an independent oversight body is to increase transparency, so if you have got an oversight body that doesn’t release its information it is is just running counter to the whole purpose of having the oversight body,” said Michele Deitch, a professor at the University of Texas at Austin’s LBJ School of Public Affairs, whose work on jail and prison oversight the task force relied on.

“Oversight is designed to shed light into what is going on in a facility so that the powers that be, whether it is legislators or prosecutors or family members or whomever, can then try to hold the agency accountable for doing whatever it should be doing. If you don’t have that transparency, you don’t have anything.”

Deitch said Hawaii is not alone among states in lacking independent oversight of prisons and jails.

“The U.S. is just really behind the rest of the world in this front,” she said.

The American Bar Association also advocates for independent oversight and monitoring of correctional facilities.