Prison cell. Credit: BigStock.

Warnings from the corrections officer killed in the Feb. 1 takeover of James T. Vaughn Correctional Center’s C-Building were ignored in the weeks leading up to the nearly 18-hour ordeal, an independent report revealed.

The breakdown, detailed for the first time Friday, was emblematic of a culture of poor leadership and communication within the Department of Correction, outlined in the 157-page report. And the failure to address those concerns likely played a role in the lead-up to the siege, which left Lt. Steven Floyd Sr. dead, the review said.

“The Independent Review Team believes that had the request for the removal of certain inmates from the C-Building—made on Jan. 20, 2017, by the very correctional officer who was killed during the incident that began on Feb. 1, 2017—been taken more seriously and carried out, the incident and the resulting death may not have occurred,” the report found.

Charles M. Oberly III, a former U.S. attorney who helped to spearhead the probe, said at a Friday morning press conference that Floyd had identified “more than five” inmates by name and asked that they be removed from the building, which houses inmates transitioning between medium and maximum security designations.

Just days before Floyd’s warning, prisoners had refused to return to their cells until they spoke with a staff supervisor about conditions in C-Building, the report said. Floyd and other officers told supervisors that they believed the inmates had organized the protest, and requested that they be removed—at least temporarily—for security purposes.

Supervisors, however, never acted upon the warnings, determining that the prisoner’s disciplinary records and a lack of alternative housing supported keeping the inmates where they were, according to the report.

On Feb. 1, a group of inmates seized control of C-Building around 10:30 a.m., taking three corrections officers and a female counselor hostage in the process. Three maintenance workers were also trapped in the building’s basement. Authorities finally secured the building in the early hours of Feb. 2, after breaching the barricaded walls with a DOC backhoe.

Floyd was pronounced dead at the scene, two corrections officers were injured and another staff member was taken to the hospital for precautionary reasons. Inmates have also reported injuries and abuses at the hands of police and prison staff during the retaking.

The ordeal has set off a seven-month criminal investigation, a DOC internal review and a wrongful death lawsuit against state officials, including former Govs. Jack Markell and Ruth Ann Minner.

The criminal investigation and the DOC’s probe are both ongoing, but Attorney General Matt Denn has said that the Department of Justice plans to present indictments to a New Castle County grand jury in the case within the next two months.

Gov. John Carney also authorized the independent probe, headed by Oberly and former Delaware Family Court Judge William L. Chapman Jr., now senior counsel with Potter Anderson & Corroon. That effort produced a preliminary report in June, and Friday’s account represented the group’s final assessment of the causes and conditions at JTVCC and the DOC underlying the takeover.

Chief among the findings was the need to address a lack of staffing and forced overtime that has exhausted prison staff in recent years and endangered both officers and inmates in the state’s prisons, Carney said.

“Staffing has to be No. 1,” the governor said at a press conference, which was monitored online via a live stream provided by CBS 3.

Carney said that the DOC has been operating with 270 vacancies statewide, thanks in large part to low pay and a lack of career-advancement opportunities that have led to high turnover among corrections officers.

DOC staff working in Delaware prisons have also developed a deep distrust of the governor’s officers, and feel “unappreciated,” as their needs have gone unaddressed, the report found.

Since the Feb. 1 incident, Carney has named a new chief of the Bureau of Prisons and replaced the warden at JTVCC. He has also secured $16 million in the state’s budget to fund pay increases for corrections officers and set aside another $2.3 million to create new positions in the DOC.

However, Carney said, much work remains to be done, including improving inmate programs, providing inmates with better access to health care and updating prison facilities and technology. The next step would be to conduct a study to determine the best staffing structure, as well as the number of guards that are needed in state prisons, Carney said Friday.

The independent report also pointed to a leadership apparatus that has resulted in inconsistent expectations and supervision throughout the DOC. Prisoners told investigators that rules are enforced erratically and that adversarial attitudes among officers have caused tensions between guards and prisoners.

The report also discussed the need to build trust within Delaware’s prisons and to expand education and rehabilitation service for the 90 percent of prisoners who will one day return to their communities.

“As tragic as the unnecessary loss of life is, the incident that began on Feb. 1, 2017, spearheaded long overdue changes in the DOC that will hopefully result in better working conditions for the correctional officers and professional staff as well as living conditions for inmates,” it said.

In a federal lawsuit, Floyd’s family has pinned the failures at JTVCC on Markell and Minner, arguing that their failure to address severe staffing and training shortages created the conditions that allowed the deadly uprising to occur.

The state has moved to dismiss the lawsuit, claiming that the former executives were protected by qualified immunity. Earlier this week, Floyd family attorneys argued in a court filing that the state had an obligation to provide a safe work environment for staff and said that specific policies set forth under both administrations led directly to the takeover.

Instead of working to fix the understaffing problem, the attorneys said that Markell instituted a policy of leaving at least 90 DOC positions vacant at any given time. Both administrations, they said, hid the crisis from lawmakers and the public.

Carney, who is not a party to the lawsuit, said Friday that his administration was committed to working to implement the recommendations outlined in the report. Many of the suggested changes would require legislative approval, and Carney said he would work closely with lawmakers when they return to Dover in January.