Just weeks before Javarick Gantt was killed inside a Baltimore jail, a pair of jail and prison experts touring the facility and its medical infirmary noted “alarming” conditions for people with disabilities, overcrowded dorms forcing rows of people to sleep on plastic “boats” on a gym floor, and “extremely harsh” living conditions in the inpatient mental health unit — harsher than any death row or supermax detention centers they had previously toured.

The killing of Gantt, who was deaf and used sign language to communicate, has spurred an array of urgent questions about the state-run jail’s ability to properly house people with disabilities, as well as the mechanics of a criminal legal system that forced the 34-year-old to await the outcome of his relatively minor assault charges behind bars at a facility ill-suited to care for him.

Gantt was found “unresponsive” in an undisclosed location within the jail around 6:30 a.m. on Oct. 9, officials have said. His death was later ruled a homicide.

In August and September, a pair of representatives from the American Civil Liberties Union conducted tours of the Baltimore Central Booking and Intake Center, where Gantt was held, and its medical infirmary, the first such visit since the COVID-19 pandemic. After their first visit, they documented a list of deficiencies for mental health and medical care, prompting the facility’s medical monitor to deride the fact that the facility failed to properly track people with disabilities and coordinate accommodations for them.

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The ACLU’s findings are outlined in a letter sent to the agency running the jail in August, which was filed in federal court late last week as part of the Duvall v. Hogan case, a class action that dates back to the mid 1990s.

That the Maryland Department of Public Safety and Correctional Services might have been ill-equipped to care for her son came as no surprise to Quinette Gantt, Javarick’s mother, who said she is still awaiting news of whether the agency will charge someone for her son’s killing. Though the report’s findings for people with disabilities have facility-wide implications, they focus largely on the medical infirmary.

Quinette Gantt said she was told by others Javarick was not being housed there, though she and others felt he should have been. The corrections department on Tuesday declined to provide any details about Javarick Gantt’s housing status.

“I figured something was going on there because it ain’t making sense,” Quinette Gantt said of the report on Tuesday afternoon. “Not at all.”

Javarick Gantt, 34, sits on a stoop and poses for a photograph at an unknown location in Baltimore. Gantt was murdered by an unknown assailant at a state-run jail in the city earlier this month.
Javarick Gantt, 34, sits on a stoop and poses for a photograph at an unknown location in Baltimore. Gantt was murdered by an unknown assailant at a state-run jail in the city earlier this month. (Photo courtesy of Anthony Taylor)

The Maryland corrections department did not immediately respond to a request for comment on the report’s findings on Tuesday. A 2016 settlement in Duvall v. Hogan stipulates that the agency must “ensure that plaintiffs with disabilities that require special accommodations are housed in locations that provide those accommodations.” The medical monitor overseeing the settlement has recently found the agency to be in “partial compliance” with that condition, but the latest report criticizes the department for unfixed problems and worsening conditions.

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The medical monitor cited the findings of the ACLU representatives, who described inaccessible toilets and showers that left people with disabilities complaining that they had not been able to properly clean themselves for months.

“Compounding their misery, they [people with disabilities] were not receiving clean linens or clothes with any regularity,” the ACLU said in its report of its August tour.

The report was included in a letter dated August 26 written by Corene Kendrick and David Fathi of the ACLU’s National Prison Project and addressed to a top corrections department official. It found some degree of indifference to the conditions from medical and custodial staff at the facility. For example, the report found that an ADA-accessible shower was deemed “broken” since at least May, even though it appeared to function just fine and no one could say what was wrong with it or why it had not been repaired if it was in fact broken.

One person housed in the infirmary had two broken legs that were in splints and in traction at the time of his intake to the facility in July from the hospital, the ACLU found. Though hospital doctors told the man he could not put weight on his legs and had to stay in traction, the man told the ACLU representatives visiting the infirmary that nursing staff told him he had to wheel himself to the toilet, stand up and walk on his broken legs in order to use the bathroom, which had a door that was jerry-rigged with plastic cushioning to keep it shut and a moldy, broken vent.

“The infirmary is where many of the sickest and most disabled plaintiffs are being housed, yet the clear failure by health care or custody staff to provide the most basic of housing accommodations to them was alarming,” the letter said.

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Photographs taken during an August tour of the Baltimore Central Booking and Intake Center and its medical infirmary show the conditions of a cell there, including an overflowing toilet and a thin mattress on the floor, which is chipping away. (court records)

A separate and recent report from an independent medical monitor for the jail, Dr. Michael Puisis, said that the infirmary has 24 beds in four dormitories and four individual cells “and none are currently ADA appropriate with respect to showers, toilets, beds and some equipment.”

It’s unclear whether Gantt was ever housed in the infirmary, but the findings from the ACLU and the medical monitor detail other inadequacies in how the facility manages people with disabilities. According to the settlement, the corrections department should have an “ADA coordinator,” whose role would be to ensure that the booking and intake center would provide appropriate equipment and housing for people with disabilities.

“Common sense indicates, and baseline correctional practice requires, that the person in this role must know at all times where all of the people with disabilities are housed in a carceral facility, and their living conditions,” the ACLU said in its report. “We were unable to confer with the ADA coordinator after observing and documenting these appalling conditions.”

The ACLU argued that if the agency was in fact employing such a coordinator, they were failing to address the needs of incarcerated people with disabilities “in any sort of meaningful way.”

In a self-audit, Corizon Health, which manages inmate health care in the medical infirmary, conceded that that COVID-19 “affected custody staffing and led to a few weekly medical/Custody ADA rounds being missed” in the second half of 2021, the letter from the ACLU noted.

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“If in fact such weekly rounds are occurring, there is simply no excuse for the appalling conditions in which so many of our clients in the infirmary are being confined,” the letter said.

Photographs taken during an August tour of the Baltimore Central Booking and Intake Center and its medical infirmary show recently painted showers with visible mold and a moldy and dusty air vent. (Court records)

Puisis, the medical monitor, wrote in his recent report that the agency asserted it had such a coordinator and was actively making more rounds but had not provided data to verify its claim.

He went on to state that the agency was failing to include patients in the infirmary on its logs documenting people with disabilities. In fact, the monitor wrote, none of the people mentioned in the ACLU’s letter were found on the agency’s log of people with disabilities, “indicating that they were not being followed by the ADA nurse or coordinator.”

“All ADA patients must be followed,” the medical monitor wrote.

He then downgraded the agency’s rating on its requirement to have an ADA coordinator to “partial compliance.”

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Horrific conditions described at mental health unit

The ACLU tour report took particular aim at the inpatient mental health unit at the Baltimore jail, describing people only being let out of their cells for two to three hours per week, who are “effectively held incommunicado from their attorneys and families.” That barrier on outside communication apparently applied to a one-page information sheet from the ACLU on the Duvall case, raising the hackles of the civil rights group.

People in the inpatient mental health unit were not even allowed access to religious texts, such as the Bible or the Quran, which the ACLU described as a First Amendment violation. The group said that patients were not allowed to wear clothes, “even when they have stabilized and present no active risk of harm to themselves.”

“People in the IMHU are held in the harshest and most deprived conditions we have ever encountered in any prison or jail in the United States, including in death row and “supermax” units,” the letter said.

A trans woman told the ACLU she ended up in the mental health unit for safety reasons after being threatened with being housed with men in the general population of the jail, and said she was not allowed to wear clothes despite repeatedly requesting them.

“Another person housed in the IMHU ... reported that he had no psychological problems, but rather is recovering from a head injury,” the letter said. “He too was not allowed to wear clothes.”

The conditions “might conceivably be justified for a period of hours for someone who is actively self-harming or suicidal,” the letter said. “But these conditions in the IMHU persist for weeks and months, despite the fact that many patients are held there not because they are actively suicidal, but because they are awaiting transfer to a hospital or for other reasons.”


Ben Conarck is a criminal justice reporter for The Baltimore Banner. Previously, he covered healthcare and investigations for the Miami Herald and criminal justice for the Florida Times-Union.

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