Video Deposition of Nancy Evans Recorded 09/19/2018 in Milwaukee… · 2019-02-01 · Video...

United States District Court

Eastern District of Wisconsin _____________________________

Swayzer v. Clarke

16-CV-1703

Video Deposition of

Nancy Evans

Recorded 09/19/2018 in Milwaukee, WI

10:06 am - 2:25 pm, 208 mins. elapsed

_____________________________

Magne-Script

(414) 352-5450

22107 Standard transcript with index and exhibits

Video Deposition of Nancy Evans 9/19/2018

Magne-Script Video Court Reporting 414-352-5450

Page 1

Witness

Nancy Evans

Wednesday 09/19/2018 at 10:00 by: Jeff Joseph

Leib Knott Gaynor, LLC

219 N. Milwaukee St. #710

Milwaukee, WI 53202

Swayzer v. Clarke

16-CV-1703

United States District Court

Eastern District of Wisconsin



Page 2

1 A P P E A R A N C E S

2 James J. Gende

3 Gende Law Office, S.C.

4 N28 W23000 Roundy Dr.

5 Pewaukee, WI 53072

6 On behalf of the Plaintiffs

7

8 David J. Lang

9 Judge, Lang & Katers, LLC

10 8112 W. Bluemound Rd., Suite 71

11 Milwaukee, WI 53213

12 On behalf of the Plaintiffs

13

14 Douglas S. Knott

15 Leib Knott Gaynor, LLC

16 219 N. Milwaukee St. #710


18 On behalf of the Milwaukee County Defendants

19

20 Michael P. Russart

21 Hinshaw & Culbertson

22 100 E. Wisconsin Ave. #2600

23 Milwaukee, WI 53202-4115

24 On behalf of Armor Correctional Health Services and Steven

25 Schmid



Page 3

1 Linda V. Meagher

2 Gass Weber Mullins LLC

3 241 N. Broadway, Suite 300


5 On behalf of Gina Negrette, M.D.

6

7 Jason J. Franckowiak

8 Otjen, Gendelman, Zitzer, Johnson & Weir, S.C.

9 20935 Swenson Dr. #310

10 Waukesha, WI 53186

11 On behalf of Karen Ronquillo-Horton, M.D.

12

13 Chad M. Skarpiak

14 Cunningham, Meyer & Vedrine, P.C.

15 1 E. Upper Wacker Drive, Suite 2200

16 Chicago, IL 60601

17 On behalf of Maureen White, Ph.D., Katherine Meine, Fred

18 Porlucas, and Tulay Gulsen, M.D.

19

20 Nina G. Beck

21 Godfrey & Kahn, S.C.

22 833 E. Michigan St., Suite 1800


24 On behalf of Wisconsin Health Care Liability Insurance Plan

25



Page 4

1 I N D E X

2 EXAMINATION BY PAGE NO.

3 Mr. Gende . . . . . . . . . . . . . . . . . . . . 4, 179

4 Mr. Russart . . . . . . . . . . . . . . . . . . . 179, 180

5 Mr. Knott . . . . . . . . . . . . . . . . . . . . 180

6 EXHIBIT NO. PAGE NO.

7 122 - Subpoena and Notice of Video Deposition . . 5

8 123 - Emails produced . . . . . . . . . . . . . . 6

9 124 - Additional documents reviewed for deposition 44

10 125 - Dr. Horton deposition page 225. . . . . . . 89

11 126 - Audit Services Division 8/17/18 . . . . . . 102

12 (The exhibits were scanned and returned to Mr. Gende)

13 (The sealed original transcript was sent to Mr. Gende)

14 ===========

15 E X A M I N A T I O N

16 Q Ma'am, please state your name and spell your last name

17 for the record?

18 A Nancy Evans, E-v-a-n-s.

19 Q Ms. Evans, I'm going to ask you a series of questions

20 regarding your involvement at the Milwaukee County

21 Criminal Justice Facility during your tenure as a

22 supervisor there. If you don't understand my

23 question, please tell me so and I'll attempt to

24 rephrase it in a manner that's more clear. Okay?

25 A Yes.



Page 5

1 Q If you answer my question, I will assume that you

2 understood it. Is that fair?

3 A Yes.

4 Q All your answers must be in a verbal manner because

5 the court reporter cannot take down nods of the head

6 or shrugs of the shoulders. Okay?

7 A Yes.

8 Q Finally, please allow me to ask my entire question

9 before you attempt to answer and I'll afford you the

10 same courtesy so that we can keep the record clear.

11 Okay?

12 A Yes.

13 (Exhibit 122 identified)

14 Q Ma'am, I'm going to show you what we've previously

15 marked as Exhibit No. 122. This is a copy of the

16 subpoena that you were personally served with, as well

17 as a notice of deposition attached to that subpoena.

18 Pursuant to the subpoena, there is a little box that's

19 checked "Production." Did you make any attempt to

20 generate the documents in response to this subpoena?

21 A I produced them to my attorney.

22 Q And the production request asked you to produce all

23 emails, correspondence, and/or any other document

24 exchange with David Clarke, former sheriff, and/or

25 Richard Schmidt regarding all in-custody deaths from



Page 6

1 2016 until your date of departure from the Milwaukee

2 County Sheriff's Department. Can you tell me what

3 actions you undertook to produce those documents?

4 A I looked through my personal emails and produced what

5 I found.

6 Q Did you have any access to the email that you used at

7 work?

8 A No, sir.

9 Q Did you find any personal emails with Schmidt or

10 Clarke?

11 A I found things that I forwarded to myself and I

12 produced them to my attorney.


14 Q So while we were off the record, your attorney has

15 produced two sets of documents. The first set are

16 some emails and they are Bates 1302 to 1313. So we're

17 going to mark those Exhibit No. 123. Are those the

18 emails that you're referring to?

19 A Yes.

20 Q And those emails appear to be from your work email

21 address; is that correct?

22 A Yes.

23 Q So when you looked through your personal emails, you

24 didn't find any to former Sheriff Clarke or Interim

25 Sheriff Schmidt?



Page 7

1 A No.

2 Q Were you able to produce these emails yourself or did

3 you rely on your attorney to produce these emails?

4 MR. KNOTT: Object. You can ask what -- you

5 can ask -- well, I don't understand what that

6 question is asking, but you should not answer

7 with respect to any conversations that you and I

8 had.

9 Can you narrow the question?

10 BY MR. GENDE:

11 Q Ma'am, you indicated that you did not have access to

12 your work email address, so how did you produce these

13 emails to your counsel?

14 A These were emails I forwarded to my personal email

15 account.

16 Q Why did you forward this particular set of emails that

17 have been marked as Exhibit 123 and previously marked

18 as Exhibit 111?

19 A I wanted to keep a record of them.

20 Q Why?

21 A When I was being asked for -- I believe it was

22 Attorney Knott who wanted this information and I just

23 copied myself on them, originally.

24 Q But when did you originally send them to your home

25 email address?



Page 8

1 A I have to look.

2 THE WITNESS: Do you have that date? I

3 don't have the date.

4 BY MR. GENDE:

5 Q Ma'am, you have speak up so the -- where everything is

6 on the record.

7 MR. KNOTT: You have to answer based on your

8 personal knowledge, ma'am.

9 A I don't recall.

10 BY MR. GENDE:

11 Q Was it before or after you were terminated from the

12 Milwaukee County Sheriff's Department?

13 A It was before I resigned.

14 Q And the purpose of forwarding these to your personal

15 email address before you resigned is what? Why did

16 you do that?

17 A To keep a copy.

18 Q And why was that important to you?

19 A When the attorney requested them, I felt like I would

20 need this information in the future, so I sent myself

21 a copy.

22 Q When did you leave the Milwaukee County Sheriff's

23 Department?

24 A February of 2018, February 14th.

25 Q And what attorney are you referring to?



Page 9

1 A Attorney Knott.

2 Q When did you have your first discussions with Attorney

3 Knott in relation to this case?

4 A I don't recall.

5 Q Prior to February 2018 or after February 2018?

6 A Prior to that.

7 Q How many times have you met with Attorney Knott as it

8 relates to this case?

9 A Once. Twice. I'm sorry. Twice.

10 Q Okay. And when was the first meeting?

11 A About a month ago, when I received your first

12 subpoena.

13 Q So when you got the subpoena a month ago, you had a

14 meeting with Mr. Knott?

15 A Yes.

16 Q And then today you had another meeting with Mr. Knott,

17 or at some other point in time?

18 A Some other point in time.

19 Q Okay. When was the second meeting?

20 A Monday.

21 Q All right. Was anybody else present during that

22 meeting?

23 A No.

24 Q And how long did that meeting last for?

25 A An hour or two.



Page 10

1 Q And then the first meeting, after you were served with

2 the subpoena, how long did that last for?

3 A Thirty minutes.

4 Q And was that an in-person meeting or a phone call?

5 A In person.

6 Q And the second meeting that you've described for an

7 hour to two hours, was that in person or a phone call?

8 A In person.

9 Q And then this morning, did you meet with Mr. Knott

10 again in preparation for your deposition?

11 A Yes. Those were the two times I physically met with

12 him. I spoke with him on the phone prior to leaving

13 the sheriff's office.

14 Q Okay. And how many times did you speak with Mr. Knott

15 on the phone prior to leaving the sheriff's

16 department?

17 MR. KNOTT: I'm going to object on the

18 grounds it invades attorney-client privilege.

19 It's not related to her preparation for the

20 deposition.

21 BY MR. GENDE:

22 Q Are you refusing to answer the question based on your

23 attorney's objection?

24 MR. KNOTT: To be clear, I'm directing her

25 not to answer the question.



Page 11

1 BY MR. GENDE:

2 Q I'm asking you, are you refusing to answer the

3 question based on your attorney's instruction?

4 A I will follow my attorney's instruction.

5 MR. GENDE: Okay. Let's go off the record.

6 THE REPORTER: Off the record.

7 (Off the record)

8 THE REPORTER: We're back on the record.

9 MR. GENDE: All right. So we've had some

10 discussions off the record and we will forego

11 calling the court at this point in time, but I

12 intend to inquire further.

13 BY MR. GENDE:

14 Q On how many occasions have you spoke with Mr. Knott

15 via phone prior to the subpoena that we've marked here

16 today as Exhibit 122?

17 A I don't recall.

18 Q More than five, less than five?


20 Q And were those conversations that you've described,

21 did they occur prior to February 2018?

22 A Yes.

23 Q And during the course of those conversations, you

24 decided it would be a good idea to forward emails to

25 your personal account from your work account; is that



Page 12

1 correct?

2 A Yes.

3 Q And the emails that you forwarded from your work

4 account to your personal account, you were still

5 employed by the sheriff's department, correct?

6 A Yes.

7 Q And your purpose of forwarding those emails from your

8 work account to your personal account was what? Why

9 did you do that?

10 A For my records.

11 Q And why did you feel you needed to make a record in

12 relation to Shade Swayzer's case?

13 A I don't recall my actual reason for doing it. I just

14 -- whatever the attorney wanted from me at that time,

15 I forwarded to myself.

16 Q Why were you communicating with Kayla McCullough back

17 in July of 2016, as reflected in Exhibit 111 and 123?

18 A Because I was the jail commander and she was the

19 medical administrator.

20 Q So can you explain for me why you were involved as the

21 jail commander and communicating with the medical

22 director as it relates to the death of a child while

23 in custody?

24 A Part of my role is to communicate with Medical.

25 Q Let's go over a little bit of your background. Can



Page 13

1 you give me an overview of your educational history,

2 please?

3 A I have a bachelor's degree from Cardinal Stritch

4 University in business administration.

5 Q And when did you get your B.A.?

6 A 2010.

7 Q And after --

8 A '09 or '10. I'm sorry. '09 or '10, around that time.

9 Q All right. And what was your first job after you had

10 gotten your business management degree?

11 A I was employed at the House of Corrections when I

12 finished, while I was in the school and when I

13 finished my degree.

14 Q All right. When did you first begin your employment

15 with House of Corrections?

16 A 1997.

17 Q And from '97 until 2010, did you remain with the House

18 of Corrections?

19 A Yes.

20 Q All right. In what capacity were you initially hired

21 in 1997?

22 A Correction officer.

23 Q And then over a period of time, you proceeded up in

24 the ranks?

25 A Yes.



Page 14

1 Q All right. When was your first promotion after 1997?

2 A In 2000, maybe, I made sergeant. I'm estimating the

3 time. I don't remember the exact dates, but it was

4 around that time.

5 Q Okay. And then your next promotion after sergeant?

6 A Lieutenant.

7 Q And that occurred approximately when?

8 A 2003, 2004.

9 Q And when you were promoted to lieutenant, in what

10 capacity? What part of the House of Corrections were

11 you in charge of?

12 A Lieutenants weren't -- at that time, lieutenants

13 weren't given a particular area. It was assigned

14 daily what various duties you would have.

15 Q All right. And then your next promotion, ma'am?

16 A Correction manager.

17 Q And when did that occur?

18 A 2008.

19 Q And what were your duties and responsibilities as the

20 correction manager?

21 A To oversee operations on my particular shift.

22 Q And those operations included what? What were you

23 overseeing?

24 A Staff issues, safety, security. If the supervisors

25 had any issues, I would -- they would come to me.



Page 15

1 Q Did you have to interview for the correctional manager

2 position?

3 A No.

4 Q Tell me what the promotion process was. Did you do a

5 test? Did you fill out paperwork?

6 A For the correction manager position at that time, it

7 was a temporary position and I was called into the

8 office of the assistant superintendent, Willie Brisco

9 at the time, and offered a temporary position.

10 Q How long did you remain the correction manager?

11 A I went out for leave to have my son. He was born in

12 August. At that time, my temporary position ended

13 because I was going to be on family medical leave for

14 several months, so I went back to my position as

15 lieutenant.

16 Q That was in August of 2008?

17 A Around about that time. Maybe a little bit before.

18 Q Okay. And then when did you return to the House of

19 Corrections after your maternity leave?

20 A January 2009.

21 Q In what capacity?

22 A Lieutenant.

23 Q All right. And then when was your next promotion?

24 A I'm trying to remember exactly. Sometime later that

25 year in 2009.



Page 16

1 Q And what were you promoted to?

2 A Back to captain.

3 Q Captain?

4 A Yeah. Well, correction manager. I'm sorry. They're

5 the same thing.

6 Q Was that still a temporary position or had it become

7 permanent?

8 A Permanent position.

9 Q And you were captain of what, ma'am?

10 A A shift of the daily operations.

11 Q All right. What shift were you the captain of?

12 A First shift. One of the captains.

13 Q Had your duties or responsibilities changed at all

14 from the prior promotion to that temporary position

15 that had now become permanent?

16 A Yes. It changed because there was a new

17 administration. The sheriff's office had taken over

18 the House of Correction at that time and I was

19 promoted under the sheriff's office, so things had

20 changed.

21 Q And tell me how that promotion process worked. Did

22 you have to interview with anybody, fill out

23 paperwork, take tests?

24 A I was called into the office of Inspector Richard

25 Schmidt. We had a conversation. He asked -- they had



Page 17

1 asked for resumes to become captain and I did not

2 apply. He asked me why I didn't apply. I explained

3 my reasons. We finished our conversation. I left. A

4 short time later, I received a call from him saying,

5 "I need you to fill out a application. Don't worry

6 about the shift."

7 Q And the reasons that you didn't apply for captain at

8 that point in time were what?

9 A I just had a baby. I didn't want to move shifts, and

10 I know when you take a promotion, you could possibly

11 move shifts.

12 Q So you wanted to remain on first shift?

13 A Yes.

14 Q And Inspector Schmidt told you after the interview

15 process that they would ensure that you were able to

16 remain on the first shift if you took the captain

17 position?

18 A His words were, "I need you to submit a resume by

19 Monday, and don't worry about the shift."

20 Q Okay. And then what happened next?

21 A A few days later, I received a phone call at home from

22 Inspector Schmidt, and he said something to the effect

23 of, "You probably think we want you to be a captain."

24 And I said, "Well, that's what I assumed." And he

25 said, "Well, actually, Major Mayer is retiring and



Page 18

1 we're looking at you to fill that position."

2 Q And that position was what specifically?

3 A That would -- on paper, it was the assistant

4 superintendent of the House of Correction.

5 Q Okay. In reality, what was it?

6 A It became me in charge of the whole facility.

7 Q And so in 2009, January 2009, Inspector Schmidt wanted

8 you to provide a resume, which you thought was for a

9 captain position, but ultimately he told you he wanted

10 you to take over as the major, which was the assistant

11 superintendent for the House of Correction?

12 A Right. So what actually occurred is they gave me a

13 permanent captain position; at the very same time, a

14 temporary assignment to the major, which is assistant

15 superintendent, on paper, position.

16 Q And that was January of '09.

17 A Not January. That's when I returned, several months

18 after that. I don't remember the exact day, but it

19 was sometime in 2009.

20 Q Sometime in the spring of '09, you became the

21 assistant superintendent for the House of Corrections.

22 A In a temporary position, yes.

23 Q Okay. And when did that position become permanent for

24 you?

25 A 2010, I believe.



Page 19

1 Q And did that require a further review process or

2 discussions with Inspector Schmidt or any of the other

3 decision-makers with the Milwaukee County Sheriff's

4 Department?

5 A They offered me the position.

6 Q So it wasn't something you sought; they proactively

7 came to you?

8 A Correct.

9 Q And was that Schmidt or was that somebody else in the

10 command structure?

11 A That was Inspector Schmidt.

12 Q And then when did you realize that in reality you were

13 going to be in charge of both the House of Corrections

14 and the Milwaukee County Justice Facility?

15 A In 2010, '11 -- '10 or '11, beginning of '11, they

16 sent me to Waukesha County Tech to become a sworn

17 officer. When I graduated from Waukesha, there was

18 talks about moving me downtown. A couple of months

19 later, I think, is when I got control over both

20 facilities.

21 Q And when you say "a couple months later," are you

22 talking about spring or summer of 2011?

23 A No, no, no. 2011, I went through the acad-- I

24 graduated at the end of 2011, so this would have been

25 two-thousand -- the beginning of 2012. I'm sorry.



Page 20

1 Q Okay. And who are you talking about when you say

2 "they" sent you downtown? Was it Schmidt, Clarke,

3 somebody else?

4 A Inspector Schmidt was my boss.

5 Q Did you have interaction with Sheriff Clarke?

6 A Yes.

7 Q To what extent?

8 A We had -- at that point, he was involved in the weekly

9 cabinet meetings every Tuesday or, from time to time,

10 he would call you down for questions or various

11 reasons.

12 Q The forwarding email process that you described

13 earlier in your deposition, did you forward any other

14 emails from your business to your personal account

15 during the course of your employment?

16 A Yes.

17 Q On how many occasions did you do that?



20 A Probably more than five.

21 Q More than 20, less than 20?

22 A I don't recall exactly.

23 Q Do you recall the subject matter of the other emails

24 that you were forwarding to your personal account?

25 A Different things, I would -- things I thought were



Page 21

1 important to me.

2 Q Important to you professionally? What do you mean?

3 A Things I wanted to retain for my records.

4 Q Because you felt you might need them in the future to

5 protect your position with the sheriff's department?

6 A I just felt I wanted to retain those for my records.

7 Q Do you retain those to this day, those emails?

8 A I have some emails, yes.

9 Q Have you deleted any emails that you forwarded from

10 your work account to your personal account?

11 A No.

12 Q Did the other emails that you forwarded from your

13 personal account to your work -- I'm sorry -- from

14 your work account to your personal account, did they

15 involve deaths of any other inmates?

16 MR. KNOTT: I'm going to object to the

17 question. We had an agreement, agreed to prior

18 to the deposition, that there would not be any

19 discussion of the Terrill Thomas matter. I can't

20 have you asking questions that broadly include

21 that matter. If you're not going to honor the

22 agreement, then we're going to have to have --

23 you know, do something else about the deposition.

24 BY MR. GENDE:

25 Q So I'm not asking specifically about Terrill Thomas.



Page 22

1 I just want to know generally about emails that you

2 forwarded. Did they include emails as it relates to

3 the deaths of other inmates at the Criminal Justice

4 Facility?

5 MR. KNOTT: That's the exact same question.

6 And, sir, if you can frame it excluding Terrill

7 Thomas, I have no problem with it.

8 MR. GENDE: Okay.

9 MR. KNOTT: But --

10 MR. GENDE: Let's do it that way to start

11 with.

12 MR. KNOTT: -- it's obviously a very

13 sensitive matter.

14 MR. GENDE: I understand.

15 Q It's a very sensitive matter because you're going to

16 trial in the near future, correct? That's why it's

17 sensitive?

18 MR. KNOTT: Can you just avoid that? I

19 mean...

20 MR. GENDE: Yes. I just want to confirm --

21 MR. KNOTT: Yeah. No. I mean, now you're

22 asking for her conversations with her legal

23 counsel --

24 MR. GENDE: No, I'm not.

25 MR. KNOTT: -- and perhaps with others so --



Page 23

1 MR. GENDE: No, I'm not. All right.

2 MR. KNOTT: Yeah. I know. So please just

3 be sensitive to that. And if you could frame

4 your questions in a way that respects that, I'd

5 appreciate it.

6 BY MR. GENDE:

7 Q The other emails that you forwarded from your work

8 account to your personal account, excluding anything

9 that has to do with Terrill Thomas's case, did those

10 involve other in-custody death cases?

11 A Yes.

12 Q How many other in-custody death cases did they

13 involve?

14 A The deaths that occurred while I was at the jail and

15 some statistical information about the past.

16 Q Where did you generate the statistical information

17 from the past? Where did you get that from?

18 A Information that was available.

19 Q Available where? On the sheriff's internal website?

20 Where did you get the statistical information?

21 A Various reports that have been created over the time.

22 Q Reports created at your direction or people underneath

23 your supervisory control?

24 A Even prior to me. Any death statistical information.

25 Q How far back did you look for the statistical



Page 24

1 information regarding in-custody deaths that you then

2 subsequently forwarded to your personal emails?

3 A At different times, I would be asked to produce stats

4 for my boss, and those reports I would keep a copy of.

5 Q And when you say your "boss," you're referring to

6 Inspector Schmidt?

7 A Yes.

8 Q At any point in time after you became the person in

9 charge of the House of Corrections and the Criminal

10 Justice Facility, was somebody other than Inspector

11 Schmidt your supervisor?

12 A No.

13 Q Was there any level of supervisory staff that you

14 reported to in between Inspector Schmidt or did you

15 report to him directly?

16 A I reported directly to Inspector Schmidt.

17 Q Have you ever been deposed before, ma'am?

18 A No, sir.

19 Q Other than the statistical analysis information that

20 you had forwarded from your work email to your

21 personal email, and excluding any information that you

22 may have retained on Terrill Thomas, can you tell me

23 the general core of information that would be

24 contained in the other emails as it relates to in-

25 custody deaths? Would it be -- for instance, I'll



Page 25

1 give you a few examples and you can tell me if I'm

2 right or wrong. Morbidity or Mortality Review type

3 information?

4 A No, sir.

5 Q Internal investigations by the sheriff's department?

6 A No, sir.

7 Q Excluding those two, generally, then, what would be

8 contained in those emails regarding other inmates' in-

9 custody deaths, besides statistical analysis?

10 A Without looking at them, I can't. I can generalize to

11 you. Maybe emails, discussed emails about the deaths,

12 reports, things like that that I had access to.

13 Q And the emails about the deaths, would that be

14 something you're exchanging with Inspector Schmidt or

15 other individuals at the sheriff's department?

16 A Yes.

17 Q When you would have these email conversations with

18 Inspector Schmidt, did you copy anybody else at the

19 sheriff's department?

20 A No.

21 Q Any particular -- go ahead.

22 A Can I stop you? I don't recall that there is email

23 conversations between Inspector Schmidt and I

24 regarding the deaths. I'm saying, if they asked for a

25 document, I would get calls from him or Inspector



Page 26

1 Bailey saying, "We need this document," for whatever

2 they were working on. I would retain a copy of that.

3 So I'm not saying conversations Inspector Schmidt and

4 I or anyone else had. That's not what I was saying,

5 so I wanted to clear that up.

6 Q Did you ever sit down with Inspectors Bailey or

7 Schmidt after the series of deaths, not including

8 Terrill Thomas, to discuss policies and procedures,

9 what could be done better, what issues arose as a

10 result of those deaths?

11 A Yes.

12 Q On how many occasions did you have those conversations

13 with Schmidt and Bailey?

14 A Multiple occasions.

15 Q More than ten, less than ten?

16 A I would guess ten, more than ten.

17 Q Would you sit down with the two of them together,

18 would it be separately? Generally, how would those

19 proceed?

20 MR. KNOTT: Object to foundation, and it's

21 multiple.

22 I guess he's asking you generally.

23 A Generally, it would be separate. If Bailey was

24 looking for something, it might start a conversation.

25 If Schmidt was looking for something, it might start a



Page 27

1 conversation. Most of my conv-- most of my

2 communication would have been with Inspector Schmidt,

3 unless Bailey was requesting information or some

4 legal. He worked with the attorneys in the civil

5 cases.

6 BY MR. GENDE:

7 Q Did you ever initiate any of these contacts with

8 Schmidt or Bailey as it relates to the in-custody

9 deaths that occurred during your tenure as the

10 commander of the jail?

11 A Sure. I would talk to Inspector -- call Inspector

12 Schmidt each time. Sure. It was my job to report it

13 to him.

14 Q And when you would call Inspector Schmidt, what was

15 the process? You'd give him notice and then what was

16 supposed to happen next?

17 A Either myself or Deputy Inspector Nyklewicz, whoever

18 got the information first, would call Inspector

19 Schmidt to notify him of a death in custody. He would

20 make the determination on who was to be called in to

21 investigate it.

22 Q "He" being Schmidt?

23 A "He" being Schmidt, yes.

24 Q And generally, who was used to investigate the in-

25 custody deaths? Was it detectives, Internal Affairs?



Page 28

1 MR. KNOTT: Vague and multiple.

2 BY MR. GENDE:

3 Q Was there a specific department within the sheriff's

4 office that would be assigned to investigate in-

5 custody deaths?

6 A Yes. Every death, people from our organization would

7 come, but they wouldn't lead the investigation unless

8 ordered by Inspector Schmidt. So Internal Affairs,

9 our Criminal Investigation Division, show up, and then

10 Inspector -- based off of his order, MPD, Waukesha, or

11 whoever he determined to head up the investigation

12 would also come in.

13 Q What responsibility did you have as the commander of

14 the jail to preserve evidence once you were notified

15 of an in-custody death?

16 MR. KNOTT: Object to the form of the

17 question. It's vague, overly broad, and touches

18 upon a central issue in the Terrill Thomas

19 matter, and I'm not going to have her explain it.

20 I'm going to direct her not to answer on the

21 basis of our agreement prior to the deposition as

22 well as the parallel Terrill Thomas civil matter

23 and criminal matters.

24 BY MR. GENDE:

25 Q So any question that I ask today, based on your



Page 29

1 attorney's objections, I want you to assume precludes

2 any of your involvement or lack of involvement in the

3 Terrill Thomas matter. Generally speaking, I'd like

4 to know what your obligations were, if any, and maybe

5 they were none, to preserve evidence as it relates to

6 in-custody deaths.

7 MR. KNOTT: James, you understand completely

8 the sensitivity of that topic, that is, the

9 subject of the criminal charges. And you had an

10 agreement that you weren't going to go into that,

11 and now if you're going to do it in a veiled way,

12 then we're just going to have to terminate the

13 deposition.

14 MR. GENDE: So I don't know that it's in a

15 veiled way, but I do need to understand how

16 evidence was preserved in Shade Swayzer's case.

17 So let's --

18 MR. KNOTT: Why don't you ask about Shade

19 Swayzer's case.

20 MR. GENDE: Okay.

21 Q Let me ask you this. What was your obligation, if

22 any, to ensure that evidence as it relates to Shade

23 Swayzer and the death of her baby while in custody

24 preservation? What did you have to do to preserve

25 evidence in that regard?



Page 30

1 MR. KNOTT: I'm going to object on the same

2 grounds. James, you understand that that is a

3 request for an opinion that is not specific to

4 Shade Swayzer. If you're not going to respect

5 the agreement that we had, then we just need to

6 go to court as I was intending to do before we

7 reached an agreement.

8 MR. GENDE: Well, I'll reserve my right to

9 ask that question in this deposition, and if it's

10 not answered, we certainly can go to court.

11 Q And in the event that our position is found to be

12 substantiated, then we'll have to bring you back,

13 ma'am. Do you understand that?

14 MR. KNOTT: Just ask the next question,

15 please.

16 MR. GENDE: All right.

17 Q Did you make any attempt to preserve evidence in the

18 Shade Swayzer matter as it relates to the in-custody

19 death of her baby?

20 A No. That wasn't my role.

21 Q Whose role was it?

22 A The detectives.

23 Q And when you say "the detectives," are you talking

24 about the Criminal Investigation Division, the

25 Internal Affairs Division? Which detectives are you



Page 31

1 referring to?

2 A With every death, it's treated as a criminal

3 investigation at the beginning.

4 MR. KNOTT: Ms. Evans, I need to have -- I

5 need you to be careful for yourself, so please

6 speak to the Shade Swayzer case, if you could.

7 A The Swayzer death was treated as a criminal

8 investigation until it's proved otherwise.

9 BY MR. GENDE:

10 Q You were involved in the post incident investigation,

11 true?

12 A No.

13 Q You were communicating with Kayla McCullough, were you

14 not...

15 A Yes.

16 Q ...as it relates to Ms. Swayzer's baby's death?

17 A Yes.

18 Q And how come you were communicating with Ms.

19 McCullough after Ms. Swayzer's baby died?

20 A My role would be to run jail operations and make sure

21 there's no problems that need to be immediately

22 addressed that would create a problem.

23 Q What do you mean, "problems immediately addressed"?

24 A If, for example, officers didn't do inspections, I

25 would need to address that. If there needed to be



Page 32

1 some communication with Medical, we would address that

2 together. It was to continue to operate the jail, not

3 to investigate the case. There were other people to

4 do that.

5 Q What was your understanding of the issues that

6 surrounded the death of Ms. Swayzer's baby? Was it no

7 inspections by officers, was it a failure to

8 communicate with Medical? Was there some other

9 process and procedure that was in question?


11 question.

12 A Can you repeat that, because I'm not sure what you're

13 asking.

14 BY MR. GENDE:

15 Q Sure. So you explained to me that the purpose for

16 communicating with Ms. McCullough after Shade

17 Swayzer's baby passed away was essentially to

18 understand whether or not there were any problems that

19 needed to be immediately addressed as far as the

20 operation of the jail. Did I get that right?

21 A Yes.

22 Q All right. And the issues that you were exploring was

23 whether or not inspections were properly done?

24 A Yes.

25 Q And does that mean security staff, whether they did



Page 33

1 their rounds, or are you talking about some other

2 inspections?

3 A Security staff doing their rounds.

4 Q Okay. And another issue that you mentioned was

5 whether or not there was communication between

6 Security and Medical. Is that fair?

7 A Yes.

8 Q And then the third kind of catchall that you

9 identified was what needed to be done to continue the

10 operation of the facility. Do I have that correct?

11 A Yes.

12 Q And when you mean "continue the operation of the

13 facility," you mean in a safe manner, right?

14 A Yes.

15 Q Where the health, welfare, and safety of the inmates

16 are being properly considered and taken care of, true?

17 A Yes.

18 Q All right. So in relation to the security staff

19 inspections or rounds, were you aware of any issues in

20 that regard when you were communicating with Ms.

21 McCullough?

22 A No.

23 Q As far as the communications between Security and

24 Medical as it relates to Ms. Swayzer, were you aware

25 of any issues in that regard?



Page 34

1 A Yes.

2 Q And what issues were you aware of regarding the

3 communication or lack thereof between Medical and

4 Security as it relates to Ms. Swayzer?

5 A Her housing assignment.

6 Q And how did you become familiar with that housing

7 assignment issue?

8 A I don't recall exactly. Through conversation, I'm not

9 sure with Kayla or who, but through conversations.

10 Q Did you ever speak to Lieutenant Cunningham about the

11 housing issues?

12 A No, I did not.

13 Q Kaziah Love?

14 A No, I did not.

15 Q Lieutenant Andrykowski?


17 Q Other than speaking with Kayla McCullough about the

18 housing issue as it relates to Ms. Swayzer and her

19 baby, can you tell me any other individuals you had

20 that conversation with?

21 A I would speak with the captains and they would get the

22 answers to what I needed. So if I had questions, I

23 wouldn't go right to the officer. I address them

24 through the captains and ask them, and based off what

25 they tell me or whatever, that's -- I communicated



Page 35

1 with the captains and the deputy inspector.

2 Q The deputy inspector being who?

3 A Nyklewicz. Kevin Nyklewicz.

4 Q And he was one of your subordinates?

5 A Yes.

6 Q So if you gave him an order to go get information as

7 relates to Ms. Swayzer and her baby, that's something

8 he was required to follow, correct?

9 A Yes.

10 Q And then the captains that you've mentioned, can you

11 tell me the names of those individuals that you

12 believe you had conversations with as it relates to

13 the housing assignment and Ms. Swayzer and her baby?

14 A I really don't recall which one I spoke to about it.

15 I don't.

16 Q What captains did you have underneath your supervision

17 and control back in July of 2016?

18 A If I'm remembering correctly, Duckert, Captain William

19 Duckert, Captain George Gold, Captain Janet Borucki.

20 Q Spell that last name for me? Morucki, did you say?

21 A I believe it's B-o-r-u-c-k-i.

22 Q So Duckert, Gold, Borucki. Any other captains?

23 A I'm trying to remember who the fourth one was at that

24 time, and I'm unsure.

25 Q Did any of those captains -- strike that. Were any of



Page 36

1 those captains assigned to a specific shift at the

2 Criminal Justice Facility: first shift, second shift,

3 third shift?

4 A Yes.

5 Q All right. Which ones were assigned where?

6 A I don't recall, at that time.

7 Q What discussions do you recall with Inspector Schmidt

8 about the housing assignment issue as it relates to

9 Ms. Swayzer and her baby?

10 A I don't recall specifically, but something to the

11 effect of he asked me about her housing assignment,

12 why she was in 4A, and that may have prompted me to

13 have conversations with Kayla.

14 Q Before you spoke to your captains or your deputy

15 inspector, you spoke with Inspector Schmidt and he

16 inquired why Ms. Swayzer was housed in 4A or a similar

17 inquiry?

18 A I don't recall the sequence of that, but there were

19 conversations between both. I can't tell you which

20 occurred first, second, or third. I don't recall.

21 Q And then what information was relayed to you from your

22 captains or deputy inspector that then prompted you to

23 have these communications with Ms. McCullough that's

24 part of Exhibit 111/123?

25 A I don't recall the exact conversation. I can speak to



Page 37

1 you generally. That was a long time ago.

2 Q So I don't expect you to recall exactly what was

3 discussed, but generally, if you can give me your best

4 information, that's fine.

5 A I wanted to know why she wasn't in the infirmary and

6 how the sequence of moving out of the infirmary

7 occurred.

8 Q And why did you inquire as to the reason Ms. Swayzer

9 was not in the infirmary? What concerned you in that

10 regard?

11 A I knew when she was first brought into custody, by

12 looking through the records, that that was her

13 assignment, so I wanted to know why she was moved out.

14 Q And when you say "the infirmary," that's also known as

15 the Special Medical Unit; is that correct?

16 A Yes, sir.

17 Q And then is there another name for the Special Needs

18 Unit?

19 A Mental Health Unit.

20 Q MHU?

21 A Yes.

22 Q So did you come to an understanding before

23 communicating with Ms. McCullough that Ms. Swayzer was

24 moved from the Special Medical Unit to 4A or the

25 Special Needs Unit to 4A?



Page 38

1 A I knew her movement. I knew that she was moved twice.

2 Q She was moved from the infirmary/Special Medical Unit

3 to the Special Needs Unit. You understood that,

4 right?

5 A Yes.

6 Q And then you further understood that she was moved

7 from the Special Needs Unit to 4A, correct?

8 A Correct.

9 Q And then the concern that you had which resulted in

10 your assigning captains and the deputy inspector to

11 get you information is how Ms. Swayzer was moved from

12 Special Needs to 4A, right?

13 A Oh, I believe my concern was why she was moved out of

14 the Medical Unit.

15 Q And tell me how that concern was ultimately addressed.

16 A Through conversations, emails. I believe Kayla

17 reported to me that Dr. Horton and Dr. White both

18 consulted each other and decided that her housing

19 should be in the Special Needs Mental Health Unit.

20 Q And what specifically concerned you as the commander

21 of the jail as to why Ms. Swayzer was not in the

22 infirmary when she had her baby and was in 4A? Why

23 was that a problem in your opinion as the commander?

24 MR. KNOTT: Object to the form. Misstates

25 the testimony.



Page 39

1 BY MR. GENDE:

2 Q You can answer. You can answer, ma'am.

3 MR. KNOTT: Yeah. You can answer if you're

4 able.

5 A Could you repeat the question?

6 BY MR. GENDE:

7 Q Sure. As the commander of the jail at the time Ms.

8 Swayzer lost her baby while in custody and you

9 assigned your captains and deputy inspector to bring

10 back information to you, you understood she had been

11 in the infirmary and she had gone to 4A. Why was that

12 a concern to you that she was in 4A when she had her

13 baby?

14 MR. KNOTT: Same objection.

15 BY MR. GENDE:

16 Q You can answer.

17 MR. KNOTT: Go ahead and answer.

18 A Well, a late-term pregnancy person with special needs,

19 I would want to know why they were taken out of the

20 Medical Unit.

21 BY MR. GENDE:

22 Q So I understand that aspect of the concern, but the

23 fact that she was in 4A, how was that a problem, if at

24 all, relative to a special needs individual, late-term

25 pregnancy?



Page 40

1 A 4A is a --

2 MR. KNOTT: Form.

3 Go ahead.

4 A 4A is an overflow of Special Needs Unit, so it's not

5 unusual for pregnant women to be housed in 4A.

6 BY MR. GENDE:

7 Q Well, considering it's not unusual, then why were you

8 concerned about the move from the infirmary to 4A as

9 it relates to Ms. Swayzer?

10 MR. KNOTT: Object. Again, misstating her

11 testimony. She never testified that she was

12 concerned.

13 But go ahead and answer the question.

14 A I believe I answered that, because Swayzer was a late-

15 term, special needs patient, I wanted to make sure

16 that it was doctors' orders to move her out of the

17 Medical Unit.

18 BY MR. GENDE:

19 Q Were you able to confirm whether the doctors in fact

20 ordered that Ms. Swayzer could be moved out of the

21 Medical Unit to 4A?

22 A Yes.


24 question.

25 BY MR. GENDE:



Page 41

1 Q And tell me how you --

2 MR. KNOTT: Misstates -- James...

3 MR. GENDE: Go ahead.

4 MR. KNOTT: You're misstating the facts, and

5 you know it.

6 MR. GENDE: Mr. Knott, that's inaccurate.

7 I'm asking questions based on her answers.

8 Please don't devolve into personal attacks on the

9 record.

10 MR. KNOTT: No.

11 BY MR. GENDE:

12 Q Can you --

13 MR. KNOTT: You're misstating the record.

14 She wasn't moved from the infirmary to 4A. So

15 let's try to use the facts of the case and not

16 mislead the witness, please.

17 BY MR. GENDE:

18 Q Go ahead.

19 A Okay. So, can you repeat the question?

20 Q Of course.

21 A I want to make sure I'm answering the right question.

22 Q And if you don't understand my question, I'm happy to

23 rephrase it at any point in time.

24 Is it true or untrue that you were concerned that

25 Ms. Swayzer was moved from the infirmary and ended up



Page 42

1 in 4A?

2 A That she was moved from the infirmary, yes.

3 Q And your concern that she was moved from the infirmary

4 was based on her late-term pregnancy and her special

5 needs regarding her mental health issues, correct?

6 A Yes.

7 Q And tell me why you were concerned that she was in 4A,

8 despite the fact that she was late-term pregnancy and

9 special needs with her mental health issues.

10 MR. FRANCKOWIAK: Objection.

11 Mischaracterizes testimony.

12 BY MR. GENDE:


14 A That's not what I said. My concern was making sure

15 all of her moves were authorized by medical staff.

16 Q And tell me how you made sure that all of her moves

17 were authorized by medical staff.

18 A I spoke with Medical.

19 Q And you spoke with Dr. Horton and Dr. White?

20 A Don't recall. I know I spoke with Kayla.

21 Q And tell me how Kayla assured you that Medical

22 approved of all the moves as it relates to Ms. Swayzer

23 from the infirmary to Special Needs to 4A.

24 A That's not what I answered. I inquired about her

25 moves. I later learned that Medical authorized the



Page 43

1 move from the Medical Unit to the Special Needs Unit.

2 Q Okay. Did you find out whether anybody from Medical

3 or Mental Health authorized Ms. Swayzer from being

4 moved out of Special Needs to 4A?

5 A I found out that that did not occur.

6 Q And tell me how you verified that did not occur.

7 A Through Kayla in an email here.

8 Q And once you verified that there was no Medical or

9 Mental Health approval allowing Ms. Swayzer to be

10 moved from Special Needs to 4A, what did you do in

11 response to that information, if anything?

12 A On it's face, that's not automatically an issue.

13 Special Needs -- Mental Health Unit, MHU, is a small

14 area. Oftentimes, people have to be moved into the

15 overflow areas just because of the lack of space. So

16 on it's face, that she was moved from one Mental

17 Health Unit to the overflow Mental Health Unit was not

18 an issue.

19 Q Is there some policy or procedure that you're aware of

20 that indicates 4A is an overflow Mental Health Unit

21 for SNU? Is that written somewhere?

22 A I'm not sure. Common knowledge.

23 Q Common knowledge amongst who? Who is it common

24 knowledge?

25 A The staff in the jail.



Page 44

1 Q How long has that been common knowledge for?

2 A I'm not sure.

3 Q I want to show you what we've previously marked as

4 Exhibit No. 26 in this matter. Have you seen this

5 document before?

6 A My attorney showed this to me.

7 Q And when did you see that document?

8 A Two days ago.

9 Q So I didn't see that document produced as part of your

10 production here this morning. Are there other

11 documents that you've seen that have not been

12 produced?

13 A No.

14 Q No? So can you tell me what No. 26 is?

15 A Appears to be a copy of the tier card.


17 Q All right. And I need to do a little more bookkeeping

18 before we go there. What we've marked as Exhibit No.

19 124, those are the additional documents that your

20 attorney gave you as it relates to your preparation

21 for this deposition, correct?

22 A He didn't give me this document. I saw it. These

23 were the documents I was given.

24 Q Okay. Did you see any other documents besides what

25 we've marked as 123 and 124 and 26?



Page 45

1 A No.

2 Q Okay. So tell me what the purpose of a tier card is.

3 A It follows the inmate's movement while they're in

4 custody at the Milwaukee County Jail. It identifies

5 the inmate. The officers use that to make sure

6 physically they have the right inmates in their cell,

7 and it would also document certain information about

8 the inmates.

9 Q And what certain information would be documented on

10 there besides what you've just described?

11 A Max custody, high risk, various things.

12 Q What about doctors' orders?

13 A Certainly. Sometimes, yes.

14 Q And in this particular case, doctors' orders at some

15 point were put on Ms. Swayzer's tier card that we've

16 marked Exhibit 26, correct?

17 MR. KNOTT: Object to the form.

18 BY MR. GENDE:


20 A Yes.

21 Q Now, when you assigned to your captains and your

22 deputy inspector to go out and find out how Ms.

23 Swayzer went from the infirmary and ended up in 4A and

24 they reported back to you, did they explain to you

25 whether or not there were any issues in the



Page 46

1 classification process?

2 A There were issues with -- that we went on to address

3 with the communication with Medical and Classification

4 and -- yes.

5 Q What issues were revealed as part of the

6 classification process as it relates to Ms. Swayzer's

7 movement where she ultimately ended up in 4A?

8 A There is a form that Medical fills out when they want

9 to give certain orders for an inmate, housing orders

10 or -- those forms weren't being handled correctly. So

11 we worked together to put a more efficient system of

12 everyone having those documents.

13 Q So your understanding of the issue as it relates to

14 Ms. Swayzer's movement where she ultimately ended up

15 in 4A resulted from a lack of Medical filling out the

16 proper forms that contained orders as to where Ms.

17 Swayzer was to be housed?

18 MR. FRANCKOWIAK: Objection.

19 Mischaracterizes testimony.

20 MR. RUSSART: Join.

21 A Yeah. That's not -- no. That's not what I'm saying.

22 BY MR. GENDE:

23 Q Okay. Then can you clarify?

24 A The paperwork from Medical is part of the problem,

25 with the physical paper there, not depending on an



Page 47

1 officer to write it down on a card. That's the

2 policy. The policy is to send the proper document.

3 Q Send it where?

4 A To Classification.

5 Q So Medical is to fill out certain documents as it

6 relates to special orders for an inmate, correct?

7 A Correct.

8 Q And then those special orders are to follow the

9 inmate's tier card so correctional staff are aware of

10 Medical's special orders?

11 A It would be in their file. And prior to moving a

12 person out of those areas, the captain would call or

13 lieutenant would call and check their file to make

14 sure if there's any movement restrictions.

15 Q And the paperwork that you're referring to that

16 Medical is supposed to complete as it relates to

17 special orders, is that done during the intake process

18 or at some other point in time?

19 A Various time. Whenever they make the decis-- they

20 make different decisions throughout an inmate's

21 custody sometimes. So it could be one at booking, a

22 different one down the line, whenever they make a

23 medical assessment or have some medical restriction.

24 Q So is it your understanding that once a restriction is

25 applied to an inmate, the individual in Medical that



Page 48

1 is creating that order is supposed to fill out the

2 paperwork that you've described?

3 A Yes.

4 Q So in the event that Dr. White indicated that Ms.

5 Swayzer was to remain in the Special Needs Unit, she

6 was the individual that should have filled out the

7 paperwork that you've described?

8 MR. SKARPIAK: Object. Foundation.

9 MR. FRANCKOWIAK: Join.

10 A Whoever gives the order.

11 BY MR. GENDE:

12 Q Okay. And so I'm asking you as the commander of the

13 jail and based on your testimony that you've given to

14 me today, if there's an order entered by Dr. White

15 that an inmate is to remain in Special Needs Unit,

16 that is what prompts the paperwork that you've

17 described being filled out by that particular

18 individual, correct?

19 A Yes.

20 Q If it was Nurse Meine who indicated that Ms. Swayzer

21 should remain in the Special Needs Unit, that would

22 then require her to fill out the paperwork that you've

23 just described, correct?

24 A Yes.

25 Q If it was Dr. Horton who had provided an order that



Page 49

1 Ms. Swayzer was to remain in Special Needs Unit, that

2 would have required her, then, to fill out the

3 paperwork that you've just described, correct?

4 MR. FRANCKOWIAK: Objection. Foundation.

5 A The order would indicate -- I don't know who

6 physically fills it out, her secretary could -- "per

7 Dr. Horton," "per Doctor -- Nurse Joe," this.

8 BY MR. GENDE:

9 Q Thank you for the clarification. So in the event that

10 the order is made, it's that individual's

11 responsibility to document that the order be filled

12 out.


14 BY MR. GENDE:

15 Q Is that your testimony?

16 MR. FRANCKOWIAK: Objection. Foundation,

17 vague.

18 A Can you repeat the question?

19 BY MR. GENDE:

20 Q Sure. In the event that a special order is made

21 regarding a medical or mental health condition, the

22 individual that makes that order, it is then their

23 responsibility to ensure the paperwork that you've

24 described is filled out, whether it's done by them or

25 they direct somebody to do it.



Page 50


2 BY MR. GENDE:

3 Q Is that true?

4 A Yes.

5 Q Did you determine as part of your post incident

6 investigation and your communications with Ms.

7 McCullough who failed to fill out the paperwork as it

8 relates to the special order for Ms. Swayzer to remain

9 in Special Needs?

10 MR. KNOTT: Object to form.

11 A I was not doing an investigation.


13 BY MR. GENDE:

14 Q Did you find out who failed to fill out the paperwork

15 that you've just described as it relates to Ms.

16 Swayzer?

17 MR. FRANCKOWIAK: Objection. Form.

18 A We determined there was an issue with the paperwork.

19 BY MR. GENDE:

20 Q I understand that. And the issue with the paperwork

21 that we've discussed is there was a failure to

22 complete it, so Security didn't know that Ms. Swayzer

23 was to remain in the Special Needs Unit, right?

24 MS. MEAGHER: Object to the form.




Page 51

1 A That's not the way. They didn't complete the

2 paperwork, but they did notify, via the phone,

3 Classification of the move.

4 BY MR. GENDE:

5 Q And how do you know that Classification was notified

6 via phone of the move? What are you pointing to?

7 A It was brought to my attention that an officer

8 admitted to taking the phone call and not putting it

9 on the card.

10 Q Do you know what officer that was?

11 A I now know to be Cunningham, yes.

12 Q When did you come to the understanding that it was

13 Cunningham who received the call but failed to put it

14 on the tier card?

15 A When I spoke with my attorney.

16 Q Now, as far as the paperwork that Medical is supposed

17 to initiate when a special order is implemented

18 regarding the housing of an inmate, do you have an

19 understanding of who failed to fill out that paperwork

20 on Medical's side?

21 MR. FRANCKOWIAK: Objection. Form,

22 foundation.

23 MR. KNOTT: Asked and answered.

24 BY MR. GENDE:




Page 52

1 A The doctors who gave the order.

2 Q So there's only two doctors that we've discussed thus

3 far --

4 A Dr. Horton and Dr. White.

5 Q Failed to fill out the --

6 A Or have it filled out.


8 foundation.

9 BY MR. GENDE:

10 Q Just so we're clear, because there's objections

11 coming, it was either Dr. Horton or Dr. White who

12 failed to fill out the medical forms properly or

13 direct them to have filled out properly as it relates

14 to Shade Swayzer and her child, correct?


16 foundation.

17 A Yes.

18 BY MR. GENDE:

19 Q Did you ever make any attempt to understand why Ms.

20 Swayzer's tier card was not properly filled out by

21 Cunningham prior to having discussions with your

22 attorney?

23 A No.

24 Q Was it your decision to give Cunningham a promotion

25 after Ms. Swayzer's baby died?



Page 53


2 A I don't believe that was under me. I don't recall.

3 BY MR. GENDE:

4 Q You don't know if you were the one who promoted

5 Cunningham from correctional officer to lieutenant?

6 A When did she get promoted?

7 Q At some point after Ms. Swayzer's baby died.

8 A Yes. But I wasn't -- I didn't remain at the jail the

9 entire time, so if I was the commander of the jail,

10 then, yes. I don't recall.

11 Q If you were the commander of the jail, you would have

12 had to approve Ms. Cunningham's promotion to

13 lieutenant, true?

14 A Yes.

15 Q And tell me what that process is. Does paperwork come

16 in front of you from different individuals applying

17 for the lieutenant position, do you handpick somebody?

18 Generally, how was that handled while you were the

19 commander of the jail?

20 A HR produces a list of people eligible to be promoted.

21 In discussions with the command staff, recommendations

22 are made to Inspector Schmidt who ultimately has the

23 final say on yes or no.

24 Q So you would have discussions with your captains,

25 correct?



Page 54

1 A Uh-huh.

2 Q Is that a yes?

3 A Yes. I'm sorry.

4 Q And you would discuss the various applicants and their

5 qualities, correct?

6 A Yes.

7 Q And then ultimately it would be your decision to make

8 the recommendation to Inspector Schmidt and he would

9 have final approval on any promotions?

10 A Yes.

11 Q Do you recall having any discussions with your command

12 staff about Cunningham and her promotion?


14 Q When did you leave as the commander of the county

15 jail?

16 A 2018, early -- no. '17?

17 Q Late 2017?

18 A I believe so. I'm not sure of the exact time.

19 Q So in the event that Lieutenant Cunningham received

20 her promotion prior to you leaving as commander of the

21 jail, you agree that you would have had to have

22 discussed her qualities and record with command staff

23 and then made a recommendation to Sheriff Schmidt,

24 correct?

25 A Yes.



Page 55

1 Q And when you make that recommendation, do you do it in

2 person, do you do it via email, do you send a memo?

3 A In person.

4 Q I'm sorry?

5 A In person.

6 Q Is any paper or emails exchanged with Inspector

7 Schmidt regarding promotions that you're recommending?

8 A Most time, we did them in person, but there could be

9 some. I don't know. I don't recall.

10 Q If we can return to Exhibit No. 26, do you know

11 Detective Desotell?

12 A Yes.

13 Q And tell me how you're familiar with Desotell.

14 A I know who he is from within the sheriff's office.

15 Q Have you had personal interaction with him in the

16 past?

17 A Sure. Yes.

18 Q Does he have a reputation as a good detective?

19 A As far as I know, yes.

20 Q He's never been terminated or been disciplined as far

21 as you know?

22 A I don't know of that.

23 Q When you first saw Exhibit No. 26, this would be after

24 you left the jail, correct?

25 A To the best of my recollection, I don't remember it



Page 56

1 until my attorney and I discussed it.

2 Q And as the former commander of the jail, are you able

3 to explain why Cunningham was doing late entries on

4 the tier card for Ms. Swayzer after Ms. Swayzer's baby

5 died?

6 A It did not come to that point. During the

7 investigations, I don't step into that stuff. My

8 role, as previously explained, was to make sure things

9 were smooth going forward. There are various

10 divisions within the sheriff's office that are

11 responsible for different things: the criminal

12 investigation, the Internal Affairs investigation. So

13 I was not investigating who did what wrong. I was

14 investigating, did things go well, is there anything

15 we need to fix up to make sure it goes better in the

16 future.

17 Q All right. So my question is a little bit different.

18 I'm not asking you about an investigation. But when

19 you looked at Exhibit 26 for the first time, whether

20 it was while you were still the commander or after you

21 had left the jail supervisory position, are you able

22 to tell me or explain why Cunningham would be making

23 late entries on an inmate's tier card after a baby

24 died?

25 A She should not. That's not proper procedure.



Page 57

1 Q What is the proper procedure?

2 A If you didn't make it prior to the event, she

3 shouldn't have went back and made it.

4 Q And why is that, ma'am?

5 A She should have explained it to, you know, supervisory

6 staff, and it doesn't look well when you go back and

7 do something after an incident.

8 Q And according to Desotell, he didn't have a

9 conversation about Exhibit 26 with Cunningham until

10 December of 2016, months after this occurred. Do you

11 understand that as well?

12 A I don't know.

13 MR. KNOTT: Yeah. Are you referencing the

14 exhibit?

15 MR. GENDE: I am. So --

16 MR. KNOTT: So why don't you --

17 MR. GENDE: Sure. On the exhibit there's --

18 MR. KNOTT: -- allow her to read it or point

19 out what you're talking about?

20 BY MR. GENDE:

21 Q Well, I thought you had previously reviewed this with

22 your attorney. And there's a starred handwritten

23 paragraph that says, "After interview with CO T.

24 Cunningham, No. TC89, interview conducted on

25 12/14/16." Do you see where I've read that?



Page 58

1 A Yes.

2 Q What does that mean to you as the former jail

3 commander in charge back in December of 2016?

4 A That she wrote that after her interview with Detective

5 Desotell.

6 Q She put that on the tier card after the interview,

7 right?

8 A Yes.

9 Q And you agree that's not proper procedure, correct?

10 A Correct.

11 Q Can you tell me when Cunningham advised anybody in the

12 chain of command that she failed to document this tier

13 card before her interview with Desotell?

14 MR. KNOTT: Foundation.

15 A No, I don't know.

16 BY MR. GENDE:

17 Q And what you've previously told me moments ago is that

18 Cunningham should have advised somebody within the

19 chain of command that she failed to document this

20 information prior to her putting a late entry on there

21 and prior to her being interviewed by a detective from

22 the Criminal Division, correct?

23 MR. KNOTT: What information are you talking

24 about?

25 MR. GENDE: The "Two officer plus CI move,



Page 59

1 house in MHU per Dr. White and per NP K. Meine."

2 That's the information I'm referring to.

3 MR. KNOTT: Yeah. I think you're creating a

4 false record again, Mr. Gende.

5 MR. GENDE: I'm certainly not attempting to.

6 Q So if you don't understand my question or you -- you

7 can answer no, that that's incorrect.

8 A Can you --

9 MR. KNOTT: Ms. Evans, please review the --

10 these --

11 A Okay. I don't know what you're asking. "After an

12 interview with..." Can you repeat the question?

13 BY MR. GENDE:

14 Q Sure. What is your understanding, based on your

15 review of this document both in preparation for your

16 deposition and as we sit here today, when Cunningham

17 put the late entry onto the tier card?

18 MR. KNOTT: Object. Assumes facts not in

19 evidence.

20 Go ahead.

21 A I'm not sure. After she was -- it appears by this

22 document that she wrote it after she was interviewed

23 by the detective.

24 BY MR. GENDE:

25 Q All right. And in the event that's in fact what



Page 60

1 occurred, that she wrote it after she was interviewed

2 by the detective, you would agree that that's not

3 proper procedure, correct?

4 A Correct.

5 Q And you would also agree that Cunningham should have

6 advised somebody within her chain of command the

7 failure to document this information prior to putting

8 in a late entry in December of 2016, true?

9 MR. KNOTT: Object to the form. Assumes

10 facts not in evidence.

11 A Yes.

12 BY MR. GENDE:

13 Q And why should she have reported that information

14 prior to putting the late entry in after the interview

15 with the detective?

16 MR. KNOTT: Same objection.

17 A Because she had knowledge of information that wasn't

18 given to the people at the time of the death.

19 BY MR. GENDE:

20 Q And the knowledge that you're describing is the

21 knowledge that would have been contained in the

22 medical form?

23 A Correct.

24 Q That wasn't properly filled out by the medical staff

25 that we've already discussed, right?



Page 61

1 MR. RUSSART: Object to form.


3 A Yes.

4 BY MR. GENDE:

5 Q Now, in the event that prior to Ms. Swayzer's move

6 from Special Needs to 4A, the information that's on

7 this tier card was actually there, if it was there

8 prior to the move, should Ms. Swayzer have been moved?

9 A No.

10 Q Why not?

11 A It's a doctor's order.

12 Q So you would agree as the commander of the jail,

13 Security did not have the ability to overrule a

14 doctor's order regarding a housing assignment for a

15 special needs patient, true?

16 MR. KNOTT: Object. Vague as to which move

17 we're talking about.

18 BY MR. GENDE:


20 A It depends on the circumstance.

21 Q Well, let's talk specifically about Ms. Swayzer's

22 circumstance. Considering -- strike that. Let's talk

23 about Ms. Swayzer's circumstance and the tier card

24 that's been marked as 26. I want you to assume as the

25 commander of the jail that this special direction,



Page 62

1 "House in MHU per Dr. White, per NP Meine," was on

2 that tier card before Swayzer was moved, you've

3 already told me she should not have been moved, right?

4 MR. KNOTT: Object to the form. Let's be

5 specific about the move.

6 BY MR. GENDE:

7 Q From Special Needs to 4A, right?

8 A It depends on the circumstances.

9 Q So what circumstance allowed Ms. Swayzer to be moved

10 from Special Needs despite the special instructions on

11 her tier card?

12 A There's only so much room in Special Needs, so

13 oftentimes -- I'll strike. It occurs where you have

14 to evaluate a situation, maybe in the middle of the

15 night, based simply off of space.

16 Q So in fact, if this information that was put on as a

17 late entry by Cunningham was there on the tier card,

18 Exhibit 26, before Ms. Swayzer was moved, it's your

19 testimony as the commander that Security can make a

20 decision to overrule the special order on the tier

21 card by Medical?

22 A If there's exigent circumstances.

23 Q And what exigent circumstances would allow Security to

24 overrule Medical?

25 A In that particular case, it's not -- it's a different



Page 63

1 area of Special Needs. So "exigent circumstance,"

2 meaning the cells were needed for someone who was

3 going to harm themselves or others immediately at that

4 moment, and you had no option but to find space.

5 Exigent circumstances occur when you have very limited

6 space in that area. It's my understanding that the

7 move was made, it was several days before the death

8 occurred. At any time, she could have been moved

9 back.

10 Q By whom?

11 A If there --

12 Q Who could have moved her back?

13 A If there was an issue, if Medical had an issue with

14 her assignment in 4A, they could have said, "Hey, she

15 needs to go back to the Mental Health," and it would

16 have happened. You have to make room. There's

17 limited space in these areas.

18 Q How was your correctional/security staff advised that

19 Ms. Swayzer was late-term pregnancy prior to the

20 baby's death?


22 Q Did you make any attempt to understand that as the

23 commander of the jail when a baby died in custody?

24 A I'm thinking back. Yes, that would be something you

25 want your staff to know.



Page 64

1 Q Of course you would want your staff to know, but tell

2 me what the policy or procedure was in place to ensure

3 that staff was advised that there was a late-term

4 pregnant female that they were doing security rounds

5 on.

6 A Pertinent information is to be on the inmate's tier

7 card.

8 Q Including pregnancy, correct?

9 MR. KNOTT: Object to form, foundation.

10 BY MR. GENDE:

11 Q Including pregnancy, correct?

12 A I don't know if they put a -- pertinent information

13 would be passed on.

14 Q How?

15 A There's multiple ways of communication. There's

16 logbook, there's pod sheets.

17 Q So if an inmate is late-term pregnant, that

18 information should be contained in the logbook and pod

19 sheets, correct?

20 MR. KNOTT: Object to form, foundation,

21 calls for speculation.

22 A It should be documented.

23 BY MR. GENDE:

24 Q In the logbook and pod sheets or in some other place?

25 A Those areas, tier card. There is multiple places you



Page 65

1 can document pertinent information.

2 Q Well, I want to talk about what you understand as the

3 commander. So if a female is late-term pregnant, it

4 should be in the logbook, right?

5 A That wouldn't necessarily -- let me strike the

6 logbook. That wouldn't necessarily be in the logbook.

7 That would be more of a tier card or the pod sheet

8 type of information.

9 Q So if a female is late-term pregnant, it should be on

10 the tier card, right?

11 A Yes.

12 Q It should be on the pod sheet, right?

13 A Yes.

14 Q And it should be in those two specific areas so when

15 Correctional does their security rounds, they know,

16 when they're observing a female, whether or not to be

17 looking out for a late-term pregnant individual, true?

18 A Yes.

19 Q And tell me whether that occurred in this particular

20 case.

21 A No.

22 Q Can you explain why not, as the commander of the jail

23 during the time period in question?

24 A I didn't -- I cannot because I wasn't privy to the

25 outcome of the investigations.



Page 66

1 Q And when you say "privy to the outcome of the

2 investigations," which investigations are you

3 referring to?

4 A Any of them. The initial criminal or the Internal

5 Affairs.

6 Q Did you make any attempt, as the commander of the jail

7 who was in charge of the safety and security of the

8 inmates under your supervision and control back in

9 July 2016, why the fact Ms. Swayzer was late-term

10 pregnant failed to make it to her pod sheet or tier

11 card?


13 A Yes.

14 BY MR. GENDE:

15 Q And tell me what you did in relation to that concern.

16 A I worked with Medical to come up with a better form of

17 making sure all this information was shared.

18 Q And what did you do in that regard, to make sure the

19 information would be shared going forward?

20 A I believe we set up a system where the form would be

21 emailed to the classification group as well as the

22 captains group to make sure there was no discrepancy

23 on when it was sent, who received it, that sort of

24 thing.

25 Q Now, in the event that Medical or Mental Health had



Page 67

1 given the special instruction order, had filled out

2 the paperwork that we previously discussed, you would

3 agree, had that paperwork been filled out, then the

4 late-term pregnancy information as it relates to Ms.

5 Swayzer would have made it to the pod sheet and the

6 tier card, true?


8 foundation, speculation.

9 MR. KNOTT: Foundation, speculation.

10 BY MR. GENDE:


12 A I agree it should have made it there.

13 Q Should have made it there in the event either Dr.

14 Horton, Dr. White, or Nurse Meine had initiated the

15 necessary paperwork regarding the special orders for

16 Ms. Swayzer, true?


18 foundation, speculation.

19 A Yes.

20 BY MR. GENDE:

21 Q All right. If we can go back to 111/123, and I want

22 to talk about the July 19th, 2016 email at 3:15. Ms.

23 McCullough is inquiring about specific information,

24 correct, pursuant to that email?

25 A I'm just reading.



Page 68

1 Q Sure.

2 A Okay. What was the question? I'm sorry.

3 Q Ms. McCullough is inquiring of you and the deputy

4 inspector of certain information on July 19th pursuant

5 to this email, correct?

6 A Yes.

7 Q Did you respond to her?

8 A I don't recall. I wouldn't have been able to provide

9 her with what she's asking for.

10 Q Do you know if the deputy inspector responded to Ms.

11 McCullough in relation to this email?

12 A I don't know.

13 Q So the email to you and the deputy inspector says,

14 "I'm looking to obtain the exact time that Medical and

15 Mental Health arrived in Shade Swayzer's area to

16 provide care and, if possible, when we left the area

17 as well." What attempt if any did you make to secure

18 that information for Kayla McCullough?

19 A I didn't. Nyklewicz probably was doing that. One of

20 us would have done it, so I didn't do it, he did it.

21 Q All right. And what should have been done in order to

22 get that information back to Ms. McCullough?

23 A Look through the jail logs to find out when they were

24 in and out of a certain area.

25 Q Anything else you could look at to provide when they



Page 69

1 were in and out of a certain area as it relates to

2 Medical or Mental Health?

3 A That's the information Security would have. We would

4 know what's in the jail log.

5 Q And when you say "information Security have," what are

6 you talking about?

7 A For medical -- Security doesn't keep medical records,

8 what time a certain person does this or that. They

9 will note, "Nurse in at this time, nurse out at this

10 time. Med cart in, med cart out." When we need

11 information about specific medical information, we

12 have to go to Medical to get that.

13 Q All right. So you can look at medical records, you

14 can look at jail logs. Anything else you can

15 reference to see whether or not Medical or Mental

16 Health are in front of a cell at a particular date and

17 time?

18 A Cameras.

19 Q And how long are the videos kept?

20 A They should be 90 days.

21 Q And as it relates to Ms. Swayzer, when you were aware

22 that a baby had died and the health services

23 administrator for the jail is asking you for

24 particular information about when their people were in

25 to see Ms. Swayzer, did you have access to those



Page 70

1 videotapes at the time?

2 A I could have gotten them, sure.

3 Q You could have ordered them, correct? As the

4 commander of the jail, you could have secured those

5 tapes, true?

6 A Yes.

7 Q Did you give any order for those tapes to be removed

8 or to be taped over?

9 MR. KNOTT: What tapes are you talking

10 about?

11 BY MR. GENDE:

12 Q The videotapes as it relates to 4A during the time

13 period Ms. Swayzer was housed there.

14 A No.

15 Q Did not give that order, correct?

16 A No, I did not.

17 Q Any particular reason why you as the commander of the

18 jail didn't make an attempt to secure that video of

19 the time period that Ms. Swayzer was in 4A?

20 A To answer Kayla's question, I would have looked

21 through the jail logs. For further information on her

22 medical care, Armor would have information on her

23 medical care. And again, I wouldn't investigate the

24 case because that was not my role.

25 Q Right. But you were communicating with Ms. McCullough



Page 71

1 and she asked you for specific information, and in

2 particular, "...looking to obtain the exact time that

3 Medical and Mental Health arrived in Shade Swayzer's

4 area to provide care and, if possible, when we left

5 the area as well," and you would agree that video

6 certainly would show the time --

7 A Sure. But we probab-- the night of the death, Master

8 Control logs the times each and every person is in and

9 out of an area, so that information would have been

10 provided to Kayla without the need to look at any

11 video.

12 Q Yeah, but my question is a little different.

13 Certainly the video shows exact times that people are

14 in the area of Ms. Swayzer's cell while she was housed

15 in 4A, right?

16 A Yes.

17 Q So that's one way that that information could have

18 been provided to Ms. McCullough to get the exact times

19 where care was provided and when Medical and Mental

20 Health were in and out of Ms. Swayzer's area, true?

21 A One way, not the only way.

22 Q Do you know what happened to the video while Ms.

23 Swayzer was housed in 4A?


25 question. Mr. Gende, are we pretending that the



Page 72

1 video doesn't exist?

2 MR. GENDE: Well, we've never received it,

3 so I'm ask--

4 MR. KNOTT: Yes, you have. You showed it.

5 MR. GENDE: Not the entire time. We don't

6 have every day from July 8th forward.

7 MR. KNOTT: Yeah. Well...

8 MR. GENDE: We've asked for it.

9 MR. KNOTT: So what's the question?

10 MR. GENDE: Legal objections only going

11 forward, Counsel.

12 MR. KNOTT: Why don't you not mislead the

13 witness? That's the problem, Mr. Gende.

14 MR. GENDE: I'm not attempting to. Sir,

15 legal objections only.

16 MR. KNOTT: It's improper and unethical to

17 state facts and assume facts in a question that

18 you know are not true, and that's what you're

19 doing.

20 MR. GENDE: That's not accurate.

21 Q Do you know what happened to the video while Ms.

22 Swayzer was in 4A?

23 A No.

24 Q And you made no attempt to secure it as the commander

25 of the jail, true?



Page 73

1 A True.

2 MR. KNOTT: We need to take a break. We've

3 been at it for over an hour and a half.

4 MR. GENDE: Okay.


6 (Off the record)

7 THE REPORTER: Back on the record.

8 BY MR. GENDE:

9 Q All right, ma'am, returning to the emails that you had

10 with Ms. McCullough, still on the Tuesday, July 19th

11 email. The next sentence says, "The time frame I'm

12 looking for is from when she was booked up until she

13 was transferred out to the hospital 7/7. The exact

14 times of us seeing a patient is not currently included

15 in our medical record and would like to include this

16 information as part of my investigation if possible."

17 How did you respond to her inquiry in that regard?


19 Q She goes on to say, "Would you be able to provide me

20 with this information?" Were you able to provide her

21 with that information?


23 Q In addition to the jail logs, you could have provided

24 her video, true?

25 MR. KNOTT: Object. Form.



Page 74

1 A That's not what we would typically do.

2 BY MR. GENDE:

3 Q The question is, you could have provided her video,

4 true?

5 MR. KNOTT: Are you talking about authority?

6 BY MR. GENDE:

7 Q I'm talking about you, as the commander of the jail,

8 when the health services administrator wants the exact

9 times her people were in and out as it relates to Ms.

10 Swayzer, in addition to jail logs, you could have

11 provided her video, true?

12 MR. KNOTT: It's asked and answered.

13 THE WITNESS: Yeah.

14 BY MR. GENDE:

15 Q Is that a true statement?

16 A It depends on the circumstance. I don't know that I

17 could have provided her video. Medical has their own

18 records of when they see patients, so I'm not -- I

19 don't know what I answered to Kayla. I don't recall.

20 Q But the question is, you could have provided her

21 video. Is that true?


23 MR. GENDE: It has not been answered.

24 MR. KNOTT: It's been answered.

25 BY MR. GENDE:



Page 75

1 Q Could you have provided her video, yes or no?

2 MR. KNOTT: It doesn't have to be answered

3 yes or no. It's been asked and answered. You

4 can stand by your prior answer or add to it.

5 A Yeah. I've answered.

6 BY MR. GENDE:

7 Q Well, what was your answer, because I'm uncertain,

8 ma'am? Could you have provided her video?

9 MR. KNOTT: The record reflects her answer.

10 MR. GENDE: And I believe the record

11 reflects that she hasn't answered, so I'm seeking

12 clarification.

13 Q Could you have provided her video in response to this

14 inquiry, ma'am?

15 A That's not typically done, so I wouldn't have provided

16 her video.

17 Q I understand that your answer is it's not typically

18 done, but my question is different. You could have

19 provided video had you decided to do that as the

20 commander of the jail, true?

21 A Yes.

22 Q I'd like to move on to the next page of the email as

23 it's been produced. On July 21st at 5:02 p.m., it

24 looks like another email was sent directly to you

25 regarding the MHU to 4A. Do you see that in the



Page 76

1 "Subject" line?

2 A Yes, I do.

3 Q What if anything did that mean to you when you got the

4 email, that "Subject" line?

5 A I would have to read the content of the email. I

6 can't...

7 Q Okay. You can take the opportunity to review it

8 again. I have no problem with that.

9 A She was trying to answer who authorized the move.

10 Q And that email starts with, "Hi, Major Evans. Here's

11 what I have for you so far." Did you request the

12 information that Ms. McCullough was providing per this

13 email?

14 A Yeah. As previously stated, I wanted to find out who

15 authorized her move.

16 Q Now, again, while we're looking at 123, I don't see

17 any forwarding information from your personal -- or,

18 from your professional email to your personal email.

19 Is your personal email address on here somewhere in

20 these emails?

21 A No.

22 Q So these emails that are being produced are solely

23 from your professional email address, true?

24 MR. KNOTT: Form.

25 A These? Yes.



Page 77

1 BY MR. GENDE:

2 Q Okay. I'd like to see the personal emails that you

3 forwarded to yourself from your email address which

4 are part of the subpoena. Is there any reason why you

5 didn't produce those today?

6 MR. KNOTT: You're not going to argue with

7 the witness. We produced documents responsive to

8 the subpoena.

9 BY MR. GENDE:

10 Q So I disagree that responsive documents were produced,

11 so I'm asking you, why didn't you bring the personal

12 emails that you had sent from your professional

13 account in response to the subpoena?

14 MR. KNOTT: Counsel, I'm not going to let

15 you argue with the witness. She produced

16 documents responsive to your request.

17 BY MR. GENDE:

18 Q You can answer the question.

19 A I produced the documents you requested.

20 Q All right. And show me where those documents are at

21 that you produced that I requested from your personal

22 email.

23 MR. KNOTT: Okay. I'm not going to let you

24 browbeat the witness, either. So we produced

25 documents responsive to the subpoena. They're



Page 78

1 marked as Exhibit 123. You have them in your

2 hand.

3 BY MR. GENDE:

4 Q As part of the subpoena, ma'am, it says, "In addition,

5 produce all emails you sent to David Clarke, former

6 sheriff, from your personal and work email accounts in

7 2016." Did you check to see if you had any of those

8 personal emails to David Clarke?

9 A I did, but I didn't use my personal account to email

10 him.

11 Q All right. The timeline that Ms. McCullough provided

12 you on July 21, when you received that, did you have

13 any reason to dispute the information that Ms.

14 McCullough was providing you on July 21, '16 at 5:02

15 p.m.?

16 A Not that I recall.

17 Q All right. Now, an earlier email, on that same day,

18 was from you to Ms. McCullough. Do you see that?

19 July 21 at 3:25 p.m.? It's at the bottom of the

20 second page.

21 A I don't think I have that.

22 Q Look at the bottom of Bates 1303.

23 A Okay. Yes.

24 Q So you say, "Security cannot clear someone to move,"

25 four periods, "Who cleared her to move?" What did you



Page 79

1 mean by "Security cannot clear someone to move"?

2 A They don't have the authorization to move someone out

3 of the Medical Unit or Special Needs Unit.

4 Q So when you say, "Security cannot clear someone to

5 move," you're talking about Correctional can't take

6 somebody out of the Medical or Special Needs Unit

7 without Medical or Mental Health approval.

8 A Unless there's exigent circumstances.

9 Q Okay. And where did you say that in your email?

10 A I didn't.

11 Q So when you said, "Security cannot clear someone to

12 move," was that accurate or inaccurate when you made

13 that representation?

14 A It's accurate.

15 Q And then you go on to say, "Who cleared her to move?"

16 What did you mean by that inquiry?

17 A Who cleared her to move.

18 Q Meaning Medical, Mental, Security? Who were you

19 referring to?

20 A If I'm asking Kayla, it's Medical or Mental Health.

21 Q And Kayla responded to you, and we started with that

22 email, indicating that nobody from Medical or Mental

23 Health cleared her to move, true?

24 A Correct.

25 Q And how did you respond to that?



Page 80

1 A I don't see my response here and I don't recall.

2 Q So within five -- well, actually, the 14th, from the

3 14th to the 21st, you knew a baby had died. There was

4 a question about why Ms. Swayzer was in 4A when the

5 baby died. You were communicating with the health

6 services administrator for Armor about how this move

7 occurred, correct?

8 A Correct.

9 Q And you said, "Security cannot clear someone to move.

10 Who cleared her to move?" and Ms. McCullough's

11 response was nobody from Medical or Mental Health

12 cleared the move, right?

13 A Uh-huh.

14 Q Is that a yes?

15 A Yes.

16 Q And then what attempt did you make to find out how Ms.

17 Swayzer got moved after that if Medical and Mental

18 Health didn't allow it?

19 A Our attempt was to fix the problem. The detectives

20 were investigating who did what wrong. My attempts

21 were to resolve any issues. The detectives had the

22 case and they were investigating it, so I don't...

23 Q You were the commander of the jail. Who was more

24 responsible than you to fix this problem?

25 A We have --



Page 81


2 question.

3 A We have different roles. It's compartmentalized. You

4 know, different areas take over different things,

5 specialties.

6 BY MR. GENDE:

7 Q But I'm asking you as the commander of the jail. Was

8 there somebody more responsible to fix the problem of

9 this unapproved move other than yourself?


11 question. It's asked and answered.

12 A Yeah. I answered I was fixing the issue.

13 BY MR. GENDE:

14 Q So you were primarily the one responsible for fixing

15 the issue of this unapproved move as the commander of

16 the jail. Is that accurate?

17 MR. KNOTT: Form. Asked and answered.

18 BY MR. GENDE:

19 Q Is that true?

20 A I fixed the issue.

21 Q Who was more responsible than you to fix the issue as

22 the commander of the jail, if anybody?

23 MR. KNOTT: James, that's the fourth time

24 you asked the question.

25 BY MR. GENDE:



Page 82

1 Q I'm asking --

2 MR. KNOTT: How many times can she answer

3 the question?

4 BY MR. GENDE:

5 Q If there's somebody that was above you that was more

6 responsible, or below you, that would be an answer to

7 the question, or the answer would be, "No, I was

8 primarily responsible."

9 A It was an issue I could address at my level, so I

10 addressed it.

11 Q And when you addressed it, did you make any attempt to

12 find out who on the Security side approved of the

13 move?

14 A Again, that's for the detectives.

15 Q So your answer would be, no, you made no attempt in

16 that regard?

17 A Not that I can recall. No.

18 Q So tell me how you're going to fix a problem on the

19 Security side where somebody was moved when you don't

20 identify who made that move?

21 A To fix lines of communication and clear direction.

22 Q And the lines of communication that needed to be fixed

23 were between Medical, Mental Health, and

24 Classification, right?

25 A Correct.



Page 83

1 Q And who got -- who in Classification was responsible

2 for putting the information on Ms. Swayzer's tier card

3 that she was late-term pregnant and had special mental

4 health needs?

5 A Whoever received the document.

6 Q So it would have been Ms. Cunningham?

7 A If she received -- yes, she received the information.

8 Q Then Ms. McCullough goes on to ask you in this email,

9 after she gives you the outline of interaction, "Were

10 you by chance able to determine who your staff spoke

11 to in Medical/Mental Health?" Did you attempt to do

12 that as the commander of the jail?


14 Q Any reason why you wouldn't have attempted to try and

15 identify that person?

16 A I would have attempted to answer her question.

17 Q All right. And did you ultimately answer her

18 question?


20 Q Do you know who it was? Was it Cunningham, was it

21 Kaziah Love, was it Lieutenant Andrykowski, was it

22 some other individual?

23 A Who...?

24 Q Who had the communication with Medical and Mental

25 Health.



Page 84

1 A Yeah. I don't recall. I don't know.

2 Q Could it have been some person other the ones I've

3 just identified: Cunningham, Andrykowski, Love?

4 A I don't know.

5 Q Did you have an understanding at some point in time

6 who it was?

7 A Not that I recall, no.

8 Q All right. Let's look at Bates 1304, next page. So

9 this is an email just before your email saying,

10 "Security cannot clear someone to move. Who cleared

11 her to move?" and you were responding to Ms.

12 McCullough's inquiry, "Hi, Major. In followup to your

13 questions in regards to who moved this patient from

14 MHU to 4A," and then she goes on to give her

15 explanation or understanding. Is that true?

16 A Reading it, yes.

17 Q All right. Did you have a written inquiry that

18 prompted this email from Ms. McCullough?

19 A I don't recall. I don't recall.

20 Q I'm trying to figure out why she's responding say--

21 A We met face-to-face, we talked. You know, I don't

22 recall. I have regular communications with Kayla.

23 Q Okay. I want to talk about just the communications as

24 it relates to Ms. Swayzer. Do you recall face-to-face

25 communications with her?



Page 85

1 MR. KNOTT: About this issue?

2 MR. GENDE: About Ms. Swayzer and the loss

3 of her baby, yes.

4 A About the transferring of patients? We had

5 conversations. Do I recall exactly what they were?

6 No.

7 Q Tell me generally what you recall about the face-to-

8 face conversations you had with Ms. McCullough as it

9 relates to Ms. Swayzer and the loss of her baby.

10 MR. RUSSART: Form.

11 A Don't recall.

12 BY MR. GENDE:

13 Q As part of the email that we're discussing at Bates

14 1304, Ms. McCullough says to you, "According to the

15 records in Classification on July 8th, 2016 at 10:46

16 p.m., Lieutenant Andrykowski, Officer Evans, Adams,

17 and Avery were reported present when moving the

18 patient from MHU to 4A." Do you have any reason to

19 dispute that?

20 A No.

21 Q Did you have an understanding that it was some other

22 group of individuals that made the move?

23 A Don't recall.

24 Q Ms. McCullough goes on to say, "When an officer

25 notifies us of a move out of MHU, Armor staff are to



Page 86

1 document it in a chart note." Was that the policy and

2 procedure in place at the time?

3 MR. RUSSART: Foundation.

4 A You're asking me about Armor's policy. I don't

5 recall.

6 BY MR. GENDE:

7 Q Ms. McCullough goes on to say, "There is no indication

8 in our medical record that a Medical/Mental Health

9 staff member was involved." Do you know what that

10 means?

11 A Yes.

12 Q What does that mean to you as the former commander of

13 the jail when Ms. Swayzer lost her baby?

14 A Reading this email, it means that no Medical or

15 Medical person authorized the move.

16 Q Any reason to dispute that as we sit here today?

17 A No.

18 Q Ms. McCullough goes on to say, "In addition, if the

19 move did occur at 10:46 p.m., a PSW is not onsite at

20 that time." Any reason to dispute that information?

21 A No.

22 Q So when Ms. McCullough tells you at 3:23 p.m. on July

23 21 that no Medical or Mental Health approved of the

24 move and your response two minutes later was,

25 "Security cannot clear someone to move. Who cleared



Page 87

1 her to move?" you never found out who did the

2 clearance, right?

3 A So, I don't recall. It looks like I was not clear on

4 the answer, so...

5 Q And you didn't tell Ms. McCullough that the move could

6 have been done based on exigent circumstances, true?

7 A I don't recall.

8 Q Well, did you put it anywhere in the emails?

9 A It's not in the email.

10 Q Did you have that conversation with her face-to-face?

11 A Don't recall.

12 Q The next sentence of this 7/21, 3:23 p.m. email says,

13 "To clarify, the collaboration between Medial," I

14 think she means Medical, "and Mental Health you

15 referred to occurred when moving the patient from SMU

16 to MHU, Special Needs, not to 4A. See 7/7/16 chart

17 note by Dr. Horton as validation." Do you have any

18 reason to dispute what Ms. McCullough has represented

19 to you in that sentence or sentences?

20 A No.

21 Q Did you look at Ms. Swayzer's medical chart history?

22 A No.

23 Q So when Ms. McCullough directed you to the 7/7/16

24 chart note by Horton as validation, you didn't review

25 that chart note, true?



Page 88

1 A Oh, I believed her.

2 Q I'm asking you, did you review the chart note as

3 validation?

4 A No.

5 Q Did you ever look at Ms. Swayzer's chart after -- I'm

6 sorry -- medical chart after the baby passed away?

7 A Don't recall.

8 Q Did you get involved with looking at the medication

9 administration record for Ms. Swayzer?

10 A Only if these things were asked to be produced by the

11 detectives. No. Otherwise, I had no need to request

12 them.

13 Q Did you have any discussions with Dr. Horton about the

14 medication administration record as it relates to Ms.

15 Swayzer after she lost her baby?


17 Q So if Dr. Horton testified that you advised Dr.

18 Horton, "Ms. Swayzer received her prenatals on July

19 14th at 4:28 -- 4:21 a.m.," would that be true or

20 untrue?

21 MR. RUSSART: Object to the form.

22 A Yeah. I wouldn't have that exact information for --

23 it would be the other way around. I would ask Dr.

24 Horton when a patient got a particular medication. I

25 don't have a chart in my office of what inmate takes



Page 89

1 medication at what time. That's not my role.

2 BY MR. GENDE:

3 Q Were you allowed to access medical charts as the

4 commander in the jail back in July 2016?

5 A No. I had to request them through Armor.

6 Q So the only way you could look at Ms. Swayzer's

7 medical or mental health history would be to seek

8 approval from Armor?

9 A Yes. I'd have to request it from them.

10 Q In writing?

11 A Not necessarily.

12 Q And that would be the same for the medication

13 administration record?

14 A Yes.

15 Q And did you seek that approval when you were trying to

16 fix the problem that we've discussed after Ms. Swayzer

17 lost her baby?

18 A Don't recall.


20 Q I want to show you what we've marked as Exhibit No.

21 125. This is some deposition testimony from Dr.

22 Horton, and we're talking about the med pass at page

23 225. The question at line 19 is --

24 MR. KNOTT: Could you put it here?

25 THE WITNESS: Okay.



Page 90

1 BY MR. GENDE:

2 Q "Question: So how do you know in fact that it

3 occurred if you don't even -- if you can't tell

4 -- or if you can't even tell who the nurse is?"

5 "Answer: This was based on Security records that

6 was provided to us during the meeting that

7 morning."

8 "Question: What Security records did you

9 receive?"

10 "Answer: I did not receive them. It was verbal.

11 Verbal information that I received from at the

12 time was Nancy Evan who was -- Nancy Evans who

13 was the one in charge."

14 Did you in fact provide that information to Dr. Horton

15 verbally, that there was a med pass done at 4:21 a.m.

16 on the morning of July 14th?

17 A If she asked that question and it was in the jail log,

18 I would have told her that.

19 Q So there would have been a jail log med pass document

20 entry at 4:21 a.m.?

21 A If the --

22 MR. KNOTT: Object to form, foundation,

23 calls for speculation.

24 A If there was a med pass at that time, it would have

25 been written in the jail log. And that's all the



Page 91

1 information I would have been privy to.

2 BY MR. GENDE:

3 Q Did you ever see a jail log for Ms. Swayzer that

4 indicated a med pass was completed at 4:21 a.m.?

5 A Yes.

6 Q On July 14th? Did you see that in preparation for

7 your deposition?

8 A Yes.

9 Q I'm sorry. You're referring to?

10 A This.

11 Q When you say "This," you're talking about Exhibit

12 what? What's the exhibit number?

13 A 123.

14 Q Okay. So that's interesting. My 123, the copy,

15 doesn't have that information, so...

16 A "4:21, nurse in for court meds."

17 THE REPORTER: I'm sorry. What?

18 MR. KNOTT: Yeah. You apparently didn't

19 take one of the copies that I brought into the

20 room, sir.

21 MS. MEAGHER: Mr. Gende, would you like --

22 MR. KNOTT: No. There's plenty of copies

23 sitting right there.

24 MS. MEAGHER: Oh, okay.

25 BY MR. GENDE:



Page 92

1 Q All right. What Bates number are you referring to,

2 ma'am?

3 A It's on page 1306, page 1, at -- let me find it, 4:21

4 a.m., and it just says, "Nurse in for court meds."

5 THE REPORTER: For what meds?

6 THE WITNESS: Court meds.

7 THE REPORTER: Thank you.

8 BY MR. GENDE:

9 Q How would that be logged? Does somebody actually have

10 to put it into the software system?

11 A Yes.

12 Q So it's not a keyed entry?

13 A Correct.

14 Q And that would have been logged in by one of the

15 correctional staff on duty on the night in question,

16 true?

17 A Yes.

18 Q Now, in the event that video shows nobody walked in

19 front of Ms. Swayzer's cell at 4:21 a.m., would you be

20 able to explain that as the former commander of the

21 jail?

22 A Yeah. This doesn't mean she was at anyone's cell. It

23 just says she was in the area, in that unit.

24 Q So it doesn't -- this entry doesn't indicate that a

25 nurse provided medications to Ms. Swayzer at 4:21 a.m.



Page 93

1 in the morning, right?

2 A Right. Correct.

3 Q It just says a nurse might have walked through there?

4 A The nurse was in for court meds.

5 Q "Court meds" means what?

6 A They do a medication pass before people leave for

7 court, so it's the time.

8 Q Does that include prenatal vitamins?

9 A Whatever is prescribed at that time.

10 Q Now, I want to go back to Bates 1304 of this same

11 exhibit. What collaboration were you referring to

12 between Medical and Mental Health as part of this

13 email sent by Ms. McCullough?



16 A Meaning it was a joint decision. Medical and Mental

17 Health agreed to the move.

18 BY MR. GENDE:

19 Q Agreed to the move from the Medical Unit to the

20 Special Needs Unit?

21 A Correct.

22 Q But Medical and Mental Health didn't agree from -- the

23 move to 4A from Special Needs, right?

24 A Correct.

25 Q And how did you -- how were you able to confirm that



Page 94

1 for Ms. McCullough, where she says, "To clarify, the

2 collaboration between Medical and Mental Health you

3 referred to occurred when moving the patient from SMU

4 to MHU"?

5 A I don't recall the conversation.

6 Q I'm sorry?

7 A I don't recall.

8 Q But how would you have known that?

9 A In prior conversations it was discussed, I'm assuming.

10 Q Prior conversations with whom?

11 A Medical.

12 Q Your prior --

13 A Captains. Yeah. Staff.

14 Q Do you recall who you had those conversations with

15 regarding the collaboration between Medical and Mental

16 Health that you were referring to when you spoke with

17 Ms. McCullough?


19 Q The next Bates number is 1305. Do you know why

20 Captain Duckert was asking you for jail logs on March

21 28th, 2017?

22 MR. KNOTT: Form.

23 A He was not.

24 BY MR. GENDE:

25 Q It says, "From" -- oh, I'm sorry. I misspoke. You



Page 95

1 were asking for the jail logs from Duckert, correct?

2 A Correct.

3 Q And why were you seeking those jail logs?

4 A I needed to get them to Dr. Shansky per Inspector

5 Bailey, according to the email.

6 Q Have you ever had any discussions with Dr. Shansky

7 about his role as the monitor for the Criminal Justice

8 Facility?

9 A Yes.

10 Q On how many occasions?

11 A Don't recall.


13 A Less than five within that year.

14 Q And the purposes for those discussions were what? He

15 would complete his inspection process and sit down

16 with you, or was there some other reason you would

17 have discussions with him?

18 A Regarding his oversight of the jail.

19 Q So he would --

20 A His report.

21 Q He would tell you what he found and then he would put

22 it in a written report?

23 A Yes.

24 Q Were you the one tasked with addressing his concerns?

25 A Some of them.



Page 96

1 Q Like what types of concerns were you tasked with

2 addressing as it relates to Dr. Shansky's monitoring

3 position?

4 A I would have to review the report to be able to answer

5 that.

6 Q Did you have any involvement in dealing with Armor and

7 their failure to adequately staff the jail based on

8 the contract?


10 A I have to -- Armor and I had discussions about their

11 staffing, yes.

12 BY MR. GENDE:

13 Q On how many occasions?

14 A Don't recall.


16 A Don't recall.

17 Q Who would you have those discussions with?

18 A Kayla, Dr. Horton.

19 Q And what would you express to Kayla and Dr. Horton

20 about the lack of staffing?



23 A It was important to get staffing levels up.

24 BY MR. GENDE:

25 Q Why?



Page 97

1 A Because -- for the best care in the jail.

2 Q Best care of the inmates?

3 A Correct.

4 Q And how often were Armor's staffing levels under the

5 contractual obligations?


7 MR. KNOTT: Foundation. Calls for

8 speculation.

9 A Don't recall.

10 BY MR. GENDE:

11 Q Did you ever make any attempt to determine the extent

12 of the staffing issues, how deficient Armor was, as

13 the commander of the jail?

14 A They provided me reports on their staffing and every

15 week what they were doing to increase their staffing,

16 so Armor and I were working on that issue, yes.

17 Q How often were they in compliance with the contract

18 while you were commander of the jail?


20 Foundation.



23 BY MR. GENDE:

24 Q Were they ever in compliance?




Page 98

1 A I'd have to look at the reports, sir. It's a long

2 time ago.

3 BY MR. GENDE:

4 Q Well, as we sit here today, being the commander of the

5 jail from 2012 to 2018, can you tell me one time

6 period where Armor was in compliance with the contract

7 as far as staffing levels are concerned?


9 MR. KNOTT: It's asked and --

10 A I was not at the jail from 2012 to 2018, sir.

11 BY MR. GENDE:

12 Q Your stay was how long with the jail?

13 A I was there initially for less than a year, and the

14 second time, I came back in August -- April of 2015.

15 Q Where were you at prior to April of 2015?

16 A Various areas of the sheriff's office.

17 Q Okay. For how long?

18 A I don't recall the exact amount of time.

19 Q More than 18 months, less than 18 months?


21 Q What were the various different positions you had with

22 the sheriff's office prior to April 2015 when you

23 returned to the jail?

24 A I head up the courts, the airport, communications.

25 Q How did you end up back at the jail in April of 2015?



Page 99

1 A I was asked to return to the jail.

2 Q By whom?

3 A Sheriff Clarke.

4 Q Did he tell you why he wanted you to return to the

5 jail?

6 A No.

7 Q Did you have an understanding of why you were being


9 A Yes.

10 Q What was your understanding?

11 A To fix some issues.

12 Q Fix what issues?

13 A At the time, there was a search and jail records

14 issue. That was brought to my attention.

15 Q What do you mean, "a search and jail records issue"?

16 A Administration felt that those were the areas they

17 wanted me to focus on when going back to the jail.

18 Q So "search" meaning what? Search of inmates' cells?

19 A The search procedure of inmates, the physical search

20 of inmates.

21 Q And then the jail records issue, what was that in

22 reference to?

23 A The paperwork with releasing, detaining, and

24 processing court information.

25 Q So after April of 2015, did you report directly to



Page 100

1 Sheriff Clarke regarding his request to have you

2 return to the jail and fix those issues?

3 A No. I reported to Inspector Schmidt.

4 Q Did Schmidt have the power to terminate you in the

5 event he felt you weren't doing a good job?

6 A Yes.

7 Q Were there any other issues Sheriff Clarke discussed

8 with you when he asked you to return in April of 2015

9 besides search and jail record issues?

10 A Staff morale.

11 Q What did he identify was the issue with staff morale?

12 A He didn't identify what the issue was. Can I take

13 that back? So those conversations identifying the

14 issues would have been with Richard Schmidt. Sheriff

15 Clarke said, "Go back to the jail," and then my

16 conversations from there are with Inspector Schmidt.

17 Q Did Sheriff Clarke call you into his office to discuss

18 your return to the jail?

19 A Yes.

20 Q And tell me what you recall about those discussions.

21 A "Do me a favor. Go back to the jail."

22 Q Did he tell you why he thought you were the person for

23 the job?

24 A No.

25 Q And your response when he says, "Do me a favor. Go



Page 101

1 back to the jail" was what?

2 A "Let me think about it."

3 Q How long did you have to think about it for?

4 A I don't recall. "You can't wait too long," so it

5 wouldn't have been a long period.

6 Q Would that have been a promotion, a demotion? How

7 would you describe that when you returned to the jail

8 in April of 2015?

9 A I went as my same rank. It was a lateral move.

10 Q Lateral move. Did Clarke tell you why he needed you

11 to do him a favor and go back to the jail in April of

12 2015?

13 A Don't recall.

14 Q How long did that conversation last?

15 A Don't recall.

16 Q Did your pay increase when you returned to the jail?

17 A No.

18 Q Did you get additional overtime hours when you


20 A No.

21 Q Did you understand what the staff morale problems were

22 when you returned to the jail?

23 A Inspector Schmidt showed me some emails related to

24 that issue prior to going to the jail, yes.

25 Q All right. What was your understanding of the staff



Page 102

1 morale issue in April of 2015?

2 A A combination of things. A lot of too much overtime,

3 not feeling heard, staffing issues.

4 Q Did that include Medical and Mental Health staffing

5 issues?

6 A No. This was Security we were addressing.

7 Q When you spoke with Sheriff Schmidt in 2015 about

8 returning to the jail, did he express any concerns

9 with the Armor contract or the lack of staffing as it

10 relates to Armor's obligations under the contract?


12 A Don't recall.

13 BY MR. GENDE:

14 Q How about Inspector Schmidt? After you told Clarke

15 that you would do him a favor and go back to the jail,

16 did Schmidt raise with you issues of Armor staffing

17 levels?


19 Q When did you become aware of issues with Armor

20 staffing levels for the first time?

21 A Can't say exactly. It would have been, you know,

22 shortly after coming back to the jail when you take a

23 look at everything.


25 Q So I want to show you what we've marked as Exhibit



Page 103

1 126. This is the introduction to a Milwaukee County

2 Office of the Comptroller Audit Services Division.

3 MR. RUSSART: What's the date on that?

4 MR. GENDE: August 17th, 2018.

5 Q Do you know Jennifer Folliard, F-o-l-l-i-a-r-d?

6 A Not that I recall, no.

7 Q Did this audit, was it commenced while you were still

8 the commander at the jail?

9 A No.

10 Q You were still in the jail in 2017, correct?

11 A No. I moved out sometime in 2017. I don't recall

12 this. When did this...

13 MR. KNOTT: Wait for the next question.

14 A If you tell me the date, I could tell you if I was

15 there.

16 BY MR. GENDE:

17 Q So were you still there on April 25th, 2018?

18 A I don't remember.

19 Q So according to a news article in the

20 Journal/Sentinel, it says, "In February, Nancy Evans,

21 the former commander of the Milwaukee County Jail, and

22 two other jail staffers were charged with certain

23 issues," and this is from an article published April

24 25th, 2018. Do you believe you were still employed

25 with the sheriff's department in February 2018?



Page 104

1 A Yes.

2 Q Okay. So you were there in two-thousand -- I'm sorry.

3 I must have misspoke. You were still employed with

4 the sheriff's department up until February of 2018,

5 correct?

6 A Correct.

7 Q So you were still the commander in 2017, correct?

8 A I moved out of the jail prior to my termination. I

9 went to a different assignment sometime in '17.

10 Q Okay. What was your new assignment in '17?

11 A I worked in administration.

12 Q Who was your commander?

13 A Sheriff Schmidt. I mean, Inspector Schmidt.

14 Q And what were your administrative tasks in 2017?

15 A When I moved -- I'm not sure on the dates; it's been a

16 while -- but when I moved, I was -- took over the role

17 of adjutant to Sheriff Clarke.

18 Q And your duties and responsibilities were what?

19 A Whatever he needed me to do. It varied.

20 Administrative things.

21 Q And did you request that move?

22 A No.

23 Q Was that a lateral move as well?

24 A Yes.

25 Q Who did you discuss with your move to being adjunct



Page 105

1 for Sheriff Schmidt -- I'm sorry -- Sheriff Clarke

2 back in 2017?

3 A Inspector Schmidt called me and said, "You're moving."

4 Q Did he indicate to you that he was upset with your

5 role as a commander of the jail and the multitude of

6 deaths there?

7 A No.

8 Q Had you ever been an adjunct to Clarke before?

9 A No.

10 Q Did you indicate to Inspector Schmidt that you didn't

11 want to make that move?

12 A No.

13 Q Were you prepared to be relieved of your command at

14 the jail?

15 A Yes.

16 Q Why was that, ma'am?

17 A I was ready for something different.

18 Q Would you describe your command role at the jail from

19 April of 2015 until you became the adjunct to Clarke

20 as successful?

21 MR. KNOTT: Object to the form. Vague,

22 overly broad, not pertinent to any issue in the

23 case.

24 BY MR. GENDE:




Page 106

1 A Certain areas.

2 Q What areas did you feel were successful?

3 MR. KNOTT: Same objections.

4 A Don't recall.

5 BY MR. GENDE:

6 Q All right. We're looking at the exhibit, the

7 Milwaukee County Auditor's Report dated August 17th,

8 2018. The Director of Audits indicates, "Our report

9 describes how during a 22-month review period, Armor

10 never achieved the minimum overall staffing level of

11 95 percent to avoid withholds from its payments from

12 Milwaukee County." Do you have any reason to dispute

13 that?

14 A No.

15 Q It goes on to document, "Staffing levels in five areas

16 include key positions of registered nurse and

17 psychiatric staffing were lower than the overall

18 average." Do you have any reason to dispute that

19 while you were the commander of the jail?

20 A No.


22 BY MR. GENDE:

23 Q Did you make any attempt to correct those staffing

24 deficiencies as it relates to registered nurses,

25 psychiatric staffing while you were the commander of



Page 107

1 the jail?


3 MR. KNOTT: Form.


5 BY MR. GENDE:

6 Q You can answer.

7 A Yes. I met with Armor regularly about their staffing

8 issues.

9 Q So I know you met with them. Tell me what you did to

10 address those deficiencies that were identified by the

11 auditor.

12 MR. RUSSART: Form, foundation.

13 BY MR. GENDE:

14 Q If anything.

15 MR. KNOTT: Form.

16 A It was not my role to do that.

17 BY MR. GENDE:

18 Q Whose role was it?

19 A Armor did their own hiring.

20 Q Right. But whose role was it to discuss with Armor

21 their inadequate staffing? Yours or somebody else's?


23 A We did that -- we discussed regularly their staffing.

24 BY MR. GENDE:

25 Q And when you say "we," who are you referring to?



Page 108

1 A Me, Nyklewicz, and Armor staff. We had weekly

2 meetings and staffing was always on the topic.

3 Q And what did you tell Armor during those weekly staff

4 meetings relative to their chronic lack of staffing as

5 to how they were going to improve that, if anything?


7 A Don't recall exact conversations.

8 BY MR. GENDE:

9 Q So let's look at the next page of the audit, under

10 "Overall Objectives." The county auditor found, the

11 first bullet point there, "Armor failed to meet the

12 minimum staffing level for all months reviewed and

13 increased its reliance on agency staffing. Armor had

14 an overall staffing level of 89 percent during the

15 review period of November 2015 to August of 2017." Do

16 you have any reason to dispute that?

17 A No.


19 BY MR. GENDE:

20 Q And you would agree that at least during a portion of

21 that November 15 to August 17, you were the jail

22 commander.

23 A Yes.

24 Q And you can't tell me as we sit here today that

25 despite that chronic understaffing that you met with



Page 109

1 Armor on a weekly basis to discuss, you can't tell me

2 one thing you did to increase their level of staffing

3 during those conversations, true?



6 MR. KNOTT: Form.

7 BY MR. GENDE:

8 Q True?

9 A I answered it. True.

10 Q Did you consider it to be an issue for the health,

11 welfare, and safety of the inmates that Armor's

12 obligation -- or, failure to meet its contractual

13 obligations were affecting the health, welfare, and

14 safety of the inmates under your supervision and

15 control?



18 question. It's argumentative.


20 BY MR. GENDE:

21 Q Sure. During the time period that you were the

22 commander of the jail, from April 2015 until sometime

23 in 2017, and considering your weekly meetings with

24 Armor staff about their failure to meet the

25 contractual obligations, did that raise a concern for



Page 110

1 you that the inmates under your supervision and

2 control were not being properly cared for by Armor?


4 A Staffing needed -- staffing was an issue. They had

5 people there from temporary agencies, so the inmates

6 were getting the care. They just didn't have the

7 full-time staff members. So, yes, inmate health care

8 is a concern.

9 BY MR. GENDE:

10 Q So you were concerned about Armor's provision of

11 health care based on their chronic understaffing,

12 true?


14 A I answered it.



17 A There's nothing else I can answer to you about that.

18 I've answered it.

19 BY MR. GENDE:

20 Q Ma'am, I need to clarify whether or not you were

21 concerned based on the chronic understaffing that's

22 reflected in this audit report as it relates to care,

23 health, welfare, and safety of the inmates under your

24 supervision and control.

25 MR. KNOTT: And she's asked and answered



Page 111

1 that, and she told you she has nothing to add,

2 so...

3 MR. RUSSART: Sir, your statement is not

4 pertinent or appropriate.

5 BY MR. GENDE:

6 Q You can answer, ma'am.

7 MR. RUSSART: There's no question. You made

8 a statement.

9 MR. GENDE: I'm entitled to seek

10 clarification.


12 Q I will. I will. I want to make it clear so we're

13 both on the same page. You had weekly meetings with

14 Armor where you raised the issue of their lack of

15 staffing, correct?


17 A Yes.

18 BY MR. GENDE:

19 Q And during those weekly meetings, at least in relation

20 to this audit, they remained only 89 percent staffed,

21 which was under their 100 percent requirement, true?


23 A True.

24 BY MR. GENDE:

25 Q And because you had weekly meetings with Armor on this



Page 112

1 issue, and at least based on this audit, which you

2 don't dispute, they were chronically understaffed at

3 89 percent, did that raise a concern in your mind that

4 the health, welfare, and safety of the inmates under

5 your supervision and control were not being properly

6 taken care of as it relates to Armor's contract?



9 BY MR. GENDE:

10 Q You can answer, ma'am.

11 A No.

12 Q Why didn't you have that concern?

13 A Based on our meetings and based on the staffing they

14 were able get from the temporary agencies and the

15 information they provided, they were able to perform

16 their contractual obligations to care for the inmates'

17 health and mental health needs.

18 Q So the seven inmates that died from 2016 through 2017,

19 do you believe Armor properly cared for them during

20 that time period?

21 MR. KNOTT: Object.


23 MR. KNOTT: I'm going to object to the

24 question and direct her not to answer pursuant to

25 the terms of this deposition.



Page 113

1 BY MR. GENDE:

2 Q Do you know how many inmates died while you were the

3 commander of the jail, ma'am?

4 A Yes, I do.

5 Q Do you believe that Armor did their job in preventing

6 the deaths that occurred while you were commander of

7 the jail?


9 MR. KNOTT: Foundation, and I'm going to

10 direct her that per the condition for this

11 deposition going forward, she's not to comment on

12 the Terrill Thomas case. So...

13 MR. GENDE: And we've already established

14 that at the outset.

15 MR. KNOTT: So, then don't ask the question

16 that includes it, please.

17 BY MR. GENDE:

18 Q I instructed you that we were to assume Terrill Thomas

19 was not part of the question and answer based on the

20 prior agreement, but I'm happy to lay that foundation

21 again.

22 The number of deaths that occurred at the jail,

23 exclusive of Terrill Thomas, while you were the

24 commander, did you feel that Armor was doing their job

25 as contracted for while you were the commander?



Page 114


2 MR. KNOTT: Vague, multiple, foundation.

3 A I can't answer that. I'm not privy to all the

4 information it would take to properly answer that

5 question right now, so I can't -- I can't answer that.

6 BY MR. GENDE:

7 Q Did you ever have an opinion as to whether or not

8 Armor was doing their job in relation to the deaths,

9 other than Terrill Thomas, that occurred while you

10 were the commander?

11 A Don't recall.

12 Q I'm sorry?


14 Q All right. I'd like to look at page 4 of this report.

15 And the last paragraph, it says, "While total Armor

16 staffing levels averaged 89 percent over the time

17 period of the audit's review, there were specific

18 categories of positions that were consistently at a

19 lower staffing level. Total staffing level includes

20 full-time agency pool and paid time off hours." Do

21 you have any reason to dispute the audit's information

22 in that regard?

23 A No.


25 BY MR. GENDE:



Page 115

1 Q So when you were discussing staffing levels with

2 Armor, you understood that despite their use of full-

3 time agency pool and part-time off hours, they remain

4 at a 89 percent staffing level, true?


6 A I see that here now, yes.

7 BY MR. GENDE:

8 Q And you have no reason to dispute that, right?


10 A True.

11 BY MR. GENDE:

12 Q So considering that Armor during this audit period

13 between November 2015 to August 2017 was chronically

14 understaffed at 89 percent, and that includes the use

15 of full-time agency pool and paid time off hours, is

16 it still your position that you had no concerns about

17 Armor's adequate provision of health care to the

18 inmates that were under your supervision and control

19 while you were the commander?


21 MR. KNOTT: Foundation, multiple, asked and

22 answered.

23 BY MR. GENDE:

24 Q Does that remain your position, ma'am?

25 A Yeah. I've answered it. I don't have anything



Page 116

1 additional to add.

2 Q Right. But now we know that at least part of the

3 foundation for your prior answer was you believed

4 positions were filled through agency and pool

5 positions and that adequate staffing may have occurred

6 through that process, right?


8 A I never denied that staffing was an issue, and we

9 continued to work on it each week, so I don't know

10 what else I can say to you on it.

11 BY MR. GENDE:

12 Q But now you know the 89 percent dealt with or included

13 pool and agency nurses, right?


15 A Staffing was an issue.

16 BY MR. GENDE:

17 Q Did you have any concerns that pool or agency nurses

18 would not be able to provide the same continuity of

19 care as Armor employees, considering the interim

20 nature of pool and agency nurses?


22 BY MR. GENDE:


24 MR. KNOTT: Join that. Foundation.




Page 117

1 BY MR. GENDE:

2 Q Sure. As the commander of the jail --

3 A Yes.

4 Q -- were you satisfied that pool and agency nurses

5 could provide the same level of medical care to

6 inmates under your supervision and control as regular

7 Armor employees?


9 A I mean, I still believe I've answered this question.

10 Staffing was an issue. Would it have been optimal to

11 be at full staff? Yes. We worked on that every week.

12 BY MR. GENDE:

13 Q But my question is different at this point. Were you

14 happy with pool and agency nurses? Were you satisfied

15 as the commander of the jail that those interim

16 staffing solutions provided by Armor was the same

17 quality of care as the regular Armor employees?


19 A Yes.

20 BY MR. GENDE:

21 Q Or do you have no opinion in that regard?

22 A To my knowledge, they were able to complete the duties

23 assigned to them by Armor.

24 Q I'm going to show you what we've previously marked as

25 Exhibit No. 42. Are these the type of policies and



Page 118

1 procedures that you were in charge of enforcing as the

2 commander of the jail during your time period there?

3 A Yes.

4 Q So it indicates, at least pursuant to these policies

5 and procedures, and we're talking about Inmate Status

6 Definitions, Disciplinary Status, Special Needs

7 Overflow. Do you see that area, "Special Needs

8 Overflow"?

9 A Yes.

10 Q Where does it say 4A is the Special Needs overflow?

11 A Well, it doesn't say that, but 4D does not house

12 women, so...

13 Q So where is the training policy and procedure for

14 Special Needs overflow as it relates to female? Where

15 is that written anywhere?

16 A It's not written in this policy.

17 Q So how did you train your security staff on Special

18 Needs overflow as it relates to females who were late-

19 term pregnant, had mental health issues, and there was

20 an order for them to remain in the Special Needs Unit?

21 Tell me how your people were trained as it relates to

22 females?

23 A We have a training division that does the training for

24 our staff.

25 Q So without a written policy and procedure on 4A, can



Page 119

1 you tell me how your people were trained as it relates

2 to females and overflow into 4A?

3 A 4A was --

4 MR. KNOTT: Object to --

5 A -- Special Needs overflow.

6 MR. KNOTT: -- the form of the question.

7 It's vague, overly broad.

8 THE REPORTER: All right. Wait. We have to

9 speak one at a time. If you hear someone begin

10 objecting, just a reminder, just stop. Thanks.

11 MR. KNOTT: So the question is vague, overly

12 broad.

13 BY MR. GENDE:


15 A 4A was designated as Special Needs overflow for female

16 inmates.

17 Q Right. But I want to know how your people were

18 trained in that regard, absent a written policy and

19 procedure.

20 MR. KNOTT: I don't understand that

21 question.

22 A I don't under--


24 question.

25 A I don't understand that, either.



Page 120

1 BY MR. GENDE:

2 Q How do you train people to follow policies and

3 procedures at the jail while you were the commander?

4 A They all -- okay. This is -- Training Division does

5 the training. I came to the jail in April of '15.

6 These policies were already in place. So please reask

7 the question because I don't know what you're asking

8 of me.

9 Q So I see a written policy and procedure on overflow

10 for 4D, which was for men, right?

11 A Yes.

12 Q I have not found a written policy and procedure for 4A

13 overflow as it relates to women. So absent a written

14 policy and procedure, can you tell me, from 2015, when

15 you became the commander at the jail, until July of

16 2016, how your security staff were trained as it

17 relates to female overflow from Special Needs to 4A?

18 MR. KNOTT: Form.

19 A I don't know what train-- what are you -- they were

20 trained to deal with special needs inmates regardless

21 of the housing unit, so I'm not -- I don't understand

22 your question.

23 BY MR. GENDE:

24 Q There's no written policy and procedure on 4A overflow

25 as it relates to females. So without the written



Page 121

1 policy and procedure, can you tell me how your

2 security staff was trained as it relates to overflow

3 for special needs females into 4A?

4 MR. KNOTT: It's vague and overly broad.

5 A I don't recall.

6 BY MR. GENDE:

7 Q Do you know how it was handled while you were the

8 commander? Regardless of the training, do you know

9 how it was handled?

10 A Yes.

11 Q How was it handled?

12 A An overflow for Special Needs.

13 Q For females.

14 A For females, yes.

15 Q All right. And tell me what your understanding of

16 that process was back in July 2016 before Ms. Swayzer

17 lost her baby.

18 A There is only three or four cells in the Mental Health

19 Unit for females, so you have to have another area to

20 put these inmates, and 4A was the area. They could

21 get the same medical treatment and everything that

22 they get in the actual Mental Health Unit. All of the

23 services that they were to get carried over,

24 regardless of -- it didn't -- the services didn't stop

25 because their housing assignment changed.



Page 122

1 Q Do you know if Ms. Swayzer had daily medical visits

2 when she was in 4A?

3 A I don't know that information without looking.

4 Q That would be one way service would stop, if daily

5 medical visits didn't occur, wouldn't it?


7 question. Speculation, foundation. What's the

8 hypothetical?

9 BY MR. GENDE:

10 Q As it relates to Ms. Swayzer, you're telling me moving

11 her to 4A doesn't change the level of care; but if

12 she's not getting daily medical visits in 4A, that

13 would be a change in the level of care, wouldn't it?

14 A What I'm saying is if she was scheduled to see a

15 doctor in the Mental Health Unit, that wouldn't change

16 because she moved to 4A, so I'm not sure what you're

17 asking me.

18 Q Tell me how your security staff was trained to make a

19 discernment between who in special needs could be

20 moved to overflow 4A based on exigency of

21 circumstances. If they go in and there's four females

22 in the Special Needs cell, how were your staff trained

23 to choose which female was going to be moved for

24 exigent circumstances?

25 A Check with Classification, look for any holds



Page 123

1 preventing them from moving, and the supervisor at the

2 time would have to make the decision based on the

3 totality of the circumstances.

4 Q The supervisor being the lieutenant on duty?

5 A Lieutenant or captain.

6 Q And assuming that the policy you've just described was

7 followed by Lieutenant Andrykowski, that he was to

8 call Classification and see if there were any holds,

9 you would agree that in the event the information that

10 is now on Ms. Swayzer's tier card that she was to

11 remain in Special Needs per Dr. White and Nurse Meine,

12 that would have prevented Andrykowski from making the

13 move, true?

14 MR. KNOTT: Object to the form. Misstates

15 the document.


17 BY MR. GENDE:


19 MR. KNOTT: Why do you want to create an

20 inaccurate record?

21 BY MR. GENDE:

22 Q You can answer the question, ma'am.

23 A Not necessarily.

24 Q All right. And tell me how your lieutenant was --

25 A All three of the --



Page 124

1 Q Go ahead.

2 A -- inmates could have a hold, then you have to balance

3 out what you do. There's a certain amount of space,

4 sir, so I can't answer that. It depends on the

5 totality of the circumstances. I'm not sure what the

6 condition of the other two female inmates were, so

7 I've answered the question. It's not a simple yes or

8 no.

9 Q All right. Tell me how, if you know, Andrykowski was

10 trained to make that totality of circumstances

11 decision as to which female who was being housed in

12 SNU based on their special needs can be moved to 4A

13 overflow.

14 A He goes through a plethora of training. I don't have

15 those records, so I can't recite that to you, but

16 people -- the sheriff's staff gets trained.

17 Q I'm sorry?

18 A I don't have his training records, so I can't speak to

19 that.

20 Q Were you trained in that regard?

21 A I don't have my training records, so I can't say

22 exactly what -- remember, in the 20 years of working

23 there, what specific trainings I had.

24 Q Well, let's just talk about 2015 through 2016 when Ms.

25 Swayzer's baby died. Would you have known what to do



Page 125

1 in the event that you were the one making the move of

2 Ms. Swayzer from Special Needs to 4A?

3 MR. KNOTT: Object to form of the question.

4 A You have to make a decision based off of the totality

5 of circumstances. That's what I would have done. And

6 without describing the exact situation, you know, I

7 can't answer that question.

8 BY MR. GENDE:

9 Q And what totality of circumstances were you trained to

10 look at?

11 A The exigent need, the other inmates and what their

12 circumstances were, would anything change for this

13 inmate by moving them to this area.

14 Q And how were you trained to decipher the other

15 inmates' circumstances between Medical and Mental

16 Health when making a decision to move somebody from

17 Special Needs to overflow in 4A?

18 A You look at their file for medical holds,

19 restrictions, that sort of thing. History would --

20 you know, assaultive behavior. There's a multitude of

21 things that go into.

22 Q Are you aware as to whether any of the other

23 individuals housed in the Special Needs Unit on July

24 14th were late-term pregnant females?




Page 126

1 Q Were you aware as to whether any of the other

2 individuals housed in Special Needs -- I'm sorry, not

3 July 14th -- on July 8th, 2016, whether they had

4 mental health issues along with late-term pregnancies?

5 A I don't recall.

6 Q Did you ever have any discussion with Andrykowski

7 about who the other individuals were in Special Needs

8 that he chose to leave there as opposed to Ms.

9 Swayzer, who he chose to move to 4A?

10 A Don't recall.

11 Q Any particular reason why you wouldn't have that

12 discussion with the lieutenant in charge of the move

13 at issue?

14 A Yes.

15 Q Why wouldn't you have that discussion with the

16 lieutenant?

17 A The captains could have talked to him. I don't

18 necessarily have conversations with -- direct

19 conversations with the lieutenants.

20 Q But you were trying to address a problem that

21 initiated with the move of Ms. Swayzer without Medical

22 or Mental Health approval, and the person that made

23 that move was a lieutenant, right?

24 A Correct.

25 Q And he was the only one with the authority to make



Page 127

1 that move, correct?

2 A I don't know who else was there that day. If a

3 captain was there, they could have done it as well.

4 Q Well, based on the email interaction that you had with

5 Ms. McCullough, you know who was there that day,

6 right?

7 A Now? Can you restate the question because I'm not

8 even sure what I'm looking for anymore. Could you

9 restate the question?

10 Q Sure. The lieutenant was the only individual,

11 Lieutenant Andrykowski was the only individual who had

12 authority to move Ms. Swayzer on the evening in

13 question, correct?

14 A No. I mean, if there was another lieutenant, if there

15 was a captain; I don't know who was all on duty that

16 night. I don't recall.

17 Q Well, we know that when Ms. Swayzer was moved. And

18 let's look at the email trail at Bates 1304. The move

19 occurred on July 8th at 10:46 p.m. Lieutenant

20 Andrykowski, Officers Evans, Adams, and Avery were

21 present, right?

22 A That's what it says.

23 Q Okay. So do you see some other supervisor there

24 besides Andrykowski?

25 A No.



Page 128

1 Q All right. And Ms. McCullough gave you this

2 information in response to your email, so now you knew

3 it was Andrykowski. And I'm asking you as the

4 commander of the jail, what prevented you from

5 inquiring of Lieutenant Andrykowski, the only

6 supervisor who made the decision on the night in

7 question, as to how he made a decision between Ms.

8 Swayzer and the other individuals in Special Needs?

9 A I don't recall.

10 Q And I'm asking you why you wouldn't do that as the

11 commander who was concerned about the movement issue,

12 talk to the supervisor who made the move? Why

13 wouldn't you do that as the commander?

14 A Don't recall.

15 Q Okay. I want to look at Exhibit No. 55A.

16 MR. RUSSART: I need a break, so...

17 MR. KNOTT: Yeah. We've been at it another

18 hour and a half.


20 (Off the record)


22 BY MR. GENDE:

23 Q Ma'am, we're going to take a look at Exhibit 55A. Did

24 you take part in Armor's Confidential Death Summary

25 Report?



Page 129

1 A What do you mean, "take part in"?

2 Q Well, when they did their post incident investigation,

3 did you provide them information, did they consult

4 with you, did you have discussions with Armor about

5 their Confidential Death Summary Report? And that's

6 the first three pages of Exhibit 55A. Let's start

7 with that.


9 A If they asked me questions about housing or whatever,

10 I don't know. But specifically for their confidential

11 report, no.

12 BY MR. GENDE:

13 Q So I want to stay on the first page for a moment,

14 where it says, "Date and type of last examination or

15 encounter, 7/14/16, med pass at 4:21." Did you give

16 Armor that information?

17 A No. I wouldn't have been able to say that.

18 Q So you don't know if that information is true or

19 untrue?

20 A I would have been able to say that they were in the

21 pod. That's as much as I could say based off of the

22 jail log.

23 Q But you couldn't tell them that, based on the jail

24 log, Ms. Swayzer actually was provided prenatal

25 vitamins at that time on that date?



Page 130

1 A No, because it didn't say that. It didn't specify who

2 was seen.

3 Q So I want to look at the next page and towards the

4 bottom with the paragraph, it says, "On 7/14..." Do

5 you see where I'm at?

6 A Uh-huh.

7 Q "On 7/14, the patient apparently had her prenatal

8 vitamins at 4:21 without any noted complaints."

9 That's not something that you would have told Armor,

10 correct?

11 A Correct.

12 Q You don't know if that's true or untrue, do you?

13 A No.

14 Q Did you make any attempt as part of your inquiries

15 into Ms. Swayzer's baby's death as to whether or not

16 there was a timely response to a medical emergency?

17 A That was for the detectives, too.

18 Q So my question to you is, did you make any inquiry in

19 that regard?

20 A Don't recall.

21 Q Did you leave it up to the detectives to determine

22 whether or not there was a timely response to a

23 medical emergency?

24 A That's how it would go, yes.

25 Q Did you make any attempt to determine when a medical



Page 131

1 emergency occurred with Ms. Swayzer while you were the

2 commander at the jail?

3 A I don't understand. Could you restate the question,

4 please?

5 Q Sure. You were the commander in the jail --

6 A Yes.

7 Q -- when the baby died, right?

8 A Yes.

9 Q Did you make any attempt to determine when a medical

10 emergency was called?

11 A You could read it in the jail log, yes.

12 Q Did you make any attempt to determine whether or not a

13 medical emergency was timely called?

14 A That would be -- I don't -- that would be interfering

15 with the investigation process. So the detectives do

16 the investigating. My role was to do things to fix

17 the jail until they were done and submitted their

18 findings.

19 Q And then who were the detectives to report to? The

20 commander of the jail or somebody else?

21 A They report to Inspector Schmidt.

22 Q Were you part of that reporting process?

23 A No.

24 Q Did you tell Inspector Schmidt you didn't want to know

25 what the results of the investigation were?



Page 132

1 A No.

2 Q Did you ever come to any opinions or understanding as

3 to whether or not a medical emergency was timely

4 called as it relates to Ms. Swayzer?

5 A I haven't been able to review the investigation

6 findings.

7 Q Since when? What do you mean you haven't been able to

8 review them?

9 A Internal Affairs never came to me and said, "Here's

10 what we found."

11 Q Did you ever --

12 A And that's how it goes.

13 Q Okay. Did you ever ask to see what the findings were?

14 A I let the process take its course.

15 Q I'm asking you, did you inquire --


17 Q So if there was an untimely response to a medical

18 emergency where a baby died, what did you do to fix

19 that problem going forward, if anything?

20 A The jail log didn't indicate that issue.

21 Q What did the jail log indicate?

22 A Inspections were timely.

23 Q Well, in the event that Ms. Swayzer said, "My water

24 broke," and one of your guards believed that she saw

25 blood in the cell, should a medical emergency have



Page 133

1 been called at that time?

2 A Depends on totality of the circumstances.

3 Q Those are the totality of the circumstances. Inmate

4 says, "My water broke," guard says, "I think I see

5 blood in the cell," as the commander, would you want a

6 medical emergency called at that time or should there

7 be some further delay?


9 question, foundation.

10 BY MR. GENDE:


12 A Yes.

13 Q "Yes," what?

14 A Medical emergency should be called.

15 Q In the event that a female says, "I believe my water

16 broke," and the guard says she thinks I see blood in

17 the cell, as the commander, you wanted a medical

18 emergency called at that time, correct?

19 MR. KNOTT: Form.

20 A Yes.

21 BY MR. GENDE:

22 Q Why?

23 A To get medical staff on scene.

24 Q And why is that important to you as the commander as

25 it relates to the health, welfare, and safety of the



Page 134

1 mother and the child?

2 A So they can get proper treatment.

3 Q Was it the policy and procedure for inmates to have

4 babies in their cell by themselves when you were the

5 commander?

6 A No.

7 Q Was it policy and procedure for inmates to have babies

8 in the jail facility when you were the commander?

9 A No.

10 Q What was the policy and procedure in that regard?

11 A You try to get them to the hospital.

12 Q Why is that, ma'am?

13 A Better equipped to deal with the birth.

14 Q Do you know why those efforts weren't made for Ms.

15 Swayzer?


17 A Repeat the question, please.

18 BY MR. GENDE:

19 Q The policy and procedure was to try and get females to

20 the hospital because there's better equipment, better

21 staff there, right?

22 A Correct.

23 Q Do you know why those efforts weren't made for Ms.

24 Swayzer before her baby died?

25 MR. KNOTT: Form.



Page 135

1 A It's my understanding they were.

2 BY MR. GENDE:

3 Q And tell me how your understanding -- how you came to

4 that understanding.

5 A Medical emergency was called, medical staff responded,

6 and according -- and the situation, they dealt with,

7 and dealt with the situation upon their arrival.

8 Q Do you know if the baby was dead or alive when the

9 medical emergency was called?

10 A It's my understanding the baby was stillborn.

11 Q And how did you come to that understanding?

12 A Based off the medical information.

13 Q So in the event that Ms. Swayzer had a baby in her

14 cell by herself and the baby was dead, or died, can

15 you explain to me why she wasn't taken to the hospital

16 before those events occurred?


18 A As soon as the officer discovers a medical situation,

19 you get help, so that's what happened.

20 BY MR. GENDE:

21 Q How do you know that happened in this particular case?

22 A According to the records I've seen.

23 Q What records are you referring to?

24 A The jail logs.

25 Q I'm sorry?



Page 136

1 A The jail logs.

2 Q And what do you discern from the jail logs that tell

3 you that Ms. Swayzer's medical emergency was properly

4 responded to? Tell me specifically what you're

5 referring to.

6 A The officer was doing her rounds; when she identified

7 a problem, she called for help; and help arrived.

8 Q But where are you getting that information from? I'd

9 like to know specifically. And you're looking at what

10 exhibit?

11 A I'm looking at Exhibit 123. But I don't know if it's

12 in here, but I read that jail log after the death.

13 Yeah. This particular log doesn't contain that

14 information.

15 Q So do you have some independent knowledge that the

16 medical emergency was appropriately responded to?

17 A I had never been privy to anything to contradict that.

18 So if the investigation turned out something, I hadn't

19 been made privy to that prior to my leaving.

20 Q Now, you previously testified that if an inmate says,

21 "My water broke," and the nurse -- I'm sorry -- the

22 correctional staff believes they see blood in the

23 cell, then a medical emergency should be immediately

24 called, right?

25 MR. KNOTT: Object to the form. Incomplete



Page 137

1 hypothetical.

2 A Yes.

3 BY MR. GENDE:

4 Q Now, if that happened in this case, Ms. Swayzer said,

5 "My water broke," and Witkowiak, the correctional

6 officer who was doing the rounds that evening, says,

7 "I think I see blood in her cell" but didn't call the

8 medical emergency, you would agree that based on your

9 prior testimony that was not a proper response by

10 Witkowiak at the time in question, true?

11 MR. KNOTT: Object.

12 A I said --

13 MR. KNOTT: Incomplete hypothetical.

14 A -- it's based off of totality of the circumstances.

15 BY MR. GENDE:

16 Q What additional circumstances would you want your

17 officer to see or know before calling a medical

18 emergency after she was told that a woman's water had

19 broke and after she believes she saw blood in the

20 cell? What more circumstances does your correctional

21 staff, Witkowiak, need to know before she calls a

22 medical emergency?

23 A Oh, she --

24 MR. KNOTT: It's vague as to circumstance.

25 THE WITNESS: Right.



Page 138

1 A The medical emergency should be called.

2 BY MR. GENDE:

3 Q And in the event that she didn't call a medical

4 emergency after being advised by Swayzer that the

5 water broke and after she believed she saw blood in

6 the cell, you would agree that she wasn't following

7 policy and procedure, true?

8 A Yes.

9 Q Now, if we can return to 55A. The next document as

10 part of this exhibit is the counseling provided by

11 Kayla McCullough to Nurse Gulsen. It's at Armor 878.

12 Have you ever seen this document before today?

13 MR. RUSSART: Form. Foundation.


15 BY MR. GENDE:

16 Q Did you have any discussions with Ms. McCullough about

17 Tulay Gulsen's involvement or lack thereof as it

18 relates to Ms. Swayzer?

19 A Could you repeat the name?

20 Q Tulay Gulsen, the doctor?


22 Q Did you request that any individuals under your

23 supervision and control be disciplined as a result of

24 the death of Ms. Swayzer's baby?

25 A No. The Internal Affairs process hadn't finished by



Page 139

1 the time I was not in that position anymore.

2 Q Did you ask that any Armor employees be disciplined as

3 a result of their involvement with Ms. Swayzer?

4 A Again, the investigation had not concluded by the time

5 I was no longer assigned there.

6 Q Let's move on to the Confidential Corrective Action

7 Plan for patient Shade Swayzer and infant. That's the

8 next document in 55A.

9 A Okay.

10 Q Were you consulted in relation to Armor's Corrective

11 Action Plan?

12 A Yes.

13 Q And if we're looking at the first paragraph there

14 where there is one, two, three, four, five, six

15 columns, under "Site responsible person," it says,

16 "Site leadership." Would that have been you?

17 A Psych leadership?

18 Q "Site responsible person," it says, "Site leadership"

19 underneath that column. Would that have been you?

20 A Yes. I don't see where you're referring to that,

21 though. Oh, site -- yes.

22 Q Okay. That would have been you?

23 A Yes.

24 MR. KNOTT: Wait a second.

25 A "Site responsible." Wait. Are you saying was I in



Page 140

1 charge of the site, or are you asking me something

2 else?

3 BY MR. GENDE:

4 Q Is "Site leadership" on this document referring to

5 you, if you know?


7 A Yeah. I don't -- I can't answer. I don't know.

8 BY MR. GENDE:

9 Q All right. So under the first paragraph it says,

10 "Area indicator problem: patient refused but medical

11 staff failed to obtain refusal form." Do you have any

12 reason to dispute that was an issue with Armor as it

13 relates to Ms. Swayzer and the care she received?


15 MR. KNOTT: Yeah. Foundation.

16 A I don't -- I don't know.

17 BY MR. GENDE:

18 Q You have no reason to believe or disbelieve that was

19 an issue?


21 A "Patient refused but informed medical, but medical

22 staff" -- "patient refused but medical staff" --

23 MR. KNOTT: You've got to either read out

24 loud --

25 THE WITNESS: I can't -- I'm trying to --



Page 141

1 MR. KNOTT: -- or read to yourself.

2 THE WITNESS: Can you read it because I have

3 a problem seeing stuff that little.

4 MR. KNOTT: I'm not much better. But you

5 want me to read --

6 THE WITNESS: Yes. What he's asking me.

7 MR. KNOTT: It says, "Area Indicator

8 Problem: the patient refused but medical staff

9 failed to obtain a refusal form."

10 BY MR. GENDE:

11 Q And the question is, do you have any information or

12 evidence as we sit here today that that's a -- that

13 wasn't a problem as it relates to the --

14 A No.

15 Q -- care and treatment of Ms. Swayzer?

16 A No.


18 A No.

19 BY MR. GENDE:

20 Q The next area indicator problem says, "Full-term

21 pregnant patient refused to be seen on 7/8, 7/11, and

22 7/12 by a provider." As the commander of the jail

23 when Ms. Swayzer's baby died, do you have any reason

24 to dispute that was a problem as it relates to Armor's

25 care and treatment?



Page 142



3 A Do I dispute that that occurred, is that what you're

4 asking me?

5 BY MR. GENDE:

6 Q As the commander of the jail, do you have any dispute

7 that this was a problem as it relates to the care and

8 treatment of Ms. Swayzer?


10 A I don't dispute the record, no.

11 BY MR. GENDE:

12 Q Now let's move on to the next page of the Root Cause

13 Analysis. Under "Problem," it says, "Patient

14 transferred from Mental Health Unit, MHU, to 4A." Do

15 you have any reason to dispute as the commander of the

16 jail that that was an issue as it relates to Ms.

17 Swayzer's care and treatment?

18 MR. KNOTT: To be accurate, because the

19 witness has said she has -- it's very difficult

20 to read this very small writing. I'm going to

21 read it complete --

22 MR. GENDE: Okay.

23 MR. KNOTT: -- because Mr. Gende did not.

24 "Patient transferred from Mental Health Unit,

25 MHU, to 4A SMT pod."



Page 143

1 THE WITNESS: Okay.

2 BY MR. GENDE:

3 Q Do you have any reason to dispute that this was a

4 problem as reflected by Armor's Corrective Action

5 Plan?


7 A A problem in -- specify what type of -- problem that

8 had occurred, a problem attributing to the death? I'm

9 not sure of the question.

10 BY MR. GENDE:

11 Q It's a problem as it relates to the care and treatment

12 that Ms. Swayzer and her baby received.


14 BY MR. GENDE:

15 Q We're not saying that it was a cause of death.


17 A Yeah. She was moved, but the medical staff could see

18 her in that area. It didn't prevent medical staff

19 from seeing her.

20 BY MR. GENDE:

21 Q Ma'am, Armor has indicated this is a problem. I'm

22 asking you as the jail commander at the time whether

23 or not you have a reason to dispute that this was a

24 problem?

25 MS. MEAGHER: Objection. Argumentative.



Page 144

1 MR. KNOTT: Join.

2 BY MR. GENDE:

3 Q And you can tell me no.

4 MR. RUSSART: And foundation.

5 BY MR. GENDE:

6 Q You may not dispute it, or you may dispute it.

7 A I think I've answ-- I mean, I don't know what else to

8 say. She was moved. There should have been

9 communication. But did it prevent medical staff from

10 seeing her? No.

11 Q Did medical staff see her after the move?

12 A I'd have to look at the records.

13 Q Did you look at the records in preparation for your

14 deposition?

15 A No, I did not.

16 Q So in the event that the move did inhibit medical or

17 mental health staff from seeing her on a daily basis,

18 that would have been a problem as it relates to Ms.

19 Swayzer, true?


21 Speculation.


23 BY MR. GENDE:


25 A Yes.



Page 145

1 Q Now, the root cause of the problem that we've just

2 discussed says, "Lack of adherence to a process for

3 movement out of high risk areas." Do you see where I

4 read that, ma'am, under "Root Cause"?

5 A Okay.

6 Q Do you have any reason to dispute that was a root

7 cause of the problem indicating where it says,

8 "Patient transferred from Mental Health Unit, MHU, to

9 4A SMT pod"?

10 A No.

11 Q What was the high risk area that Ms. Swayzer was moved

12 out of, if you know?

13 A I don't recall. I don't have that information.

14 Q Under the Corrective Action Plan, there's several

15 paragraphs that Armor decided to undertake to correct

16 the root cause of the problem that we've just

17 discussed. And the third paragraph says, "Meet with

18 Security to reiterate the importance of informing

19 Medical/Mental Health with any movements from high

20 risk areas." Do you see where I read that?

21 A I see where you read that.

22 Q Was that something that you helped institute as a

23 corrective action after Ms. Swayzer's baby died?

24 A Yes. We --

25 Q Why?



Page 146

1 A -- worked together on that. Like I said, to make

2 things better going forward, improve communications

3 going forward.

4 Q Who did you meet with in regard to that paragraph

5 number 3 that we've just discussed?

6 A In our weekly meetings, it would always be usually

7 Kayla and the doctors who were there.

8 Q And tell me what process was put in place to reiterate

9 the importance of informing medical and mental health

10 staff with any movements from high risk areas.

11 A We came up with a solution to email it. That way,

12 there is a trail of who sent it, what time, who

13 received it. Email it to the entire classification

14 group along with the captains.

15 Q And you're talking about email from Security to

16 Medical and Mental Health.

17 A No. Medical and Mental Health would, instead of just

18 calling or dropping it off on a desk, that form would

19 be emailed now.

20 Q Actually, if we could return to 878 of this exhibit,

21 this is an Unusual Occurrence Report. I misspoke when

22 we discussed it earlier.

23 A Okay.

24 Q Kayla McCullough provided an occurrence description.

25 Do you have any reason to dispute this occurrence



Page 147

1 description that Ms. McCullough provided as part of

2 the Armor Unusual Occurrence Report?

3 MR. KNOTT: Object to the form. It's a

4 paragraph long. She says she has difficulty

5 reading. It's very small type.

6 MR. GENDE: All right. We'll take it one

7 sentence at a time.

8 Q Under the occurrence description, it says, "At

9 approximately 6:04 a.m., a medical emergency was

10 called due to Security observing blood on patient's

11 blankets, bed, and floor." Do you have any reason to

12 dispute that?

13 A No.

14 Q "At 6:08, nursing staff arrived at the scene." Have

15 any reason to dispute that?

16 A No.

17 Q "The patient stated that she gave birth and quoted

18 'five minutes ago.'" Do you have any reason to

19 dispute that?

20 A No.

21 Q "The patient presented as argumentative and refused

22 the nursing staff to look at her infant which appeared

23 to be under a blanket." Any reason to dispute that?

24 A No.

25 Q "Additional security staff arrived and separated



Page 148

1 mother and infant." Any reason to dispute that?

2 A No.

3 Q "Nursing responders reported infant as cyanotic, no

4 chest movement, warm, and umbilical cord connected to

5 the mother." Any reason to dispute that?

6 A No.

7 Q "The placenta was located on the bed." Any reason to

8 dispute that?

9 A No.

10 Q "Nurses instructed call to 911 and initiated CPR."

11 Any reason to dispute that?

12 A No.

13 Q "It was reported that EMS arrived at 6:22." Any

14 reason to dispute that?

15 A No.

16 Q "Once the patient was removed from the cell, she

17 reported that she told the officer and clinic that her

18 water broke and they did nothing about it." Any

19 reason to dispute that?

20 MR. KNOTT: Object to the form. Is the

21 question whether she told them that?

22 MR. GENDE: Legal objections only, sir.

23 MR. KNOTT: Well, what is the --

24 A I want --

25 MR. KNOTT: What is the question?



Page 149

1 BY MR. GENDE:

2 Q I want to know if you dispute that statement, ma'am,

3 any reason to dispute it. That's the question.

4 MR. KNOTT: Well, she lacks foundation.

5 A Are you asking me if I dispute she said it or are you

6 asking me if I dispute the statement?

7 BY MR. GENDE:

8 Q Well, first of all, do you dispute the statement

9 that's reflected in Ms. McCullough's Unusual

10 Occurrence Report?

11 A Do I dispute the fact that the inmate made the

12 statement? I'm not sure what you're asking.

13 Q All right. Well, the first question is, the statement

14 as set forth by Ms. McCullough, do you dispute that

15 what she wrote down there is what I just read to you?

16 A Do I dispute that she reported that the inmate told --

17 that the inmate said this to her? I'm sorry. I'm not

18 -- I don't understand the question.

19 Q Sure, if you want to answer that question. Do you

20 dispute that Ms. Swayzer told the officer and the

21 clinic that her water broke and they did nothing about

22 it? Do you dispute that Ms. Swayzer said that?

23 A That's a two-part question. Do I dispute she said it,

24 or do I dispute she did nothing -- we did nothing

25 about it. That's...



Page 150

1 Q Do you dispute that Ms. Swayzer made that statement?

2 A No.

3 Q Do you dispute the contents of that statement, that

4 she told the officer and the clinic that her water

5 broke and they did nothing about it?

6 MR. KNOTT: That's...

7 A Yes.

8 BY MR. GENDE:

9 Q And if you -- and tell me why --

10 MR. KNOTT: Sir, you embed that she told

11 somebody, but...

12 MR. GENDE: That's what the statement says.

13 MR. KNOTT: Yeah. So he's asking now about

14 the content of the statement.

15 A What I'm saying is I don't dispute this statement was

16 made, for clarification.

17 BY MR. GENDE:

18 Q Now, the contents of the statement, that Ms. Swayzer

19 told the officer and the clinic that her water broke

20 and they did nothing about it, do you have information

21 that would suggest otherwise?

22 A I'm not privy to the outcome of the investigation.

23 Q So as we sit here today, you have no information that

24 disputes the contents of the statement Ms. Swayzer

25 made as reflected in Ms. McCullough's Unusual



Page 151

1 Occurrence Report.

2 A I have to give you my opinion.

3 Q I'm not asking for your opinion. I'm asking for

4 evidence to dispute that.

5 MR. KNOTT: No. You did ask for her

6 opinion, but...

7 MR. GENDE: Well, that's not the pending

8 question.

9 A What is the pending question?

10 Q What evidence do you have as we sit here today that

11 disputes the contents of Ms. Swayzer's statement that

12 she told the officer and the clinic that her water

13 broke and they did nothing about it?

14 A Evidence that the nurses came, the ambulance came, so

15 she had to have made the call.

16 Q And did they do that right when Ms. Swayzer said her

17 water broke, if you know?

18 A That, I can't answer.

19 Q All right. Per security rounds at 0535, "The patient

20 was in no distress." Do you dispute that?

21 A I'd have to look at the log.

22 Q You can look at the log.

23 A 5:35 on...

24 MR. KNOTT: The 14th.

25 A 14th.



Page 152

1 THE REPORTER: Ma'am, you have to keep to

2 keep your voice up, please.

3 THE WITNESS: Oh, I'm sorry. I'm just

4 trying to find the record.

5 A That's not what the log says.

6 BY MR. GENDE:

7 Q So you dispute that statement by Ms. McCullough?

8 A I can only go based -- it says "in the security log,"

9 and this is the security log.

10 Q Okay. What does it say in the security log?

11 A 5:35, it says -- the name is crossed out, of the

12 inmate, a crossed-out name and a crossed-out booking

13 number, "Requesting to see a nurse due to watering

14 eyes. She has been informed that is a sick call slip

15 issue. She will have to wait until med pass, until

16 the med pass nurse comes by to speak with one."

17 Q So are you looking at the 5:35 on 7/14/16, 5:35 --

18 A I'm looking at the time stamp time, 5:35.

19 Q Uh-huh.

20 A Okay. Right above that, there's another one. It

21 says, "Scheduled inspection completed. No inmates in

22 obvious physical distress."

23 Q So you don't know if that's referring to Ms. Swayzer.

24 She might have been in physical distress?

25 A Here, it says there was a log that someone was in



Page 153

1 physical distress, correct?

2 Q No. It says, "Per security rounds at 0535, the

3 patient was in no distress."

4 A Oh. Okay. I don't dispute that because it's not

5 there.

6 THE REPORTER: I'm sorry. I didn't get

7 that.

8 THE WITNESS: I don't dispute that.

9 THE REPORTER: Okay. Thanks.

10 BY MR. GENDE:

11 Q All right. The next sentence says, "At 0555, security

12 reported her as acting bizarre and the patient

13 informed security that she was sleepy." Any reason to

14 dispute that?

15 A No.

16 Q It goes on to say in Ms. McCullough's report, "At that

17 point, the officer noticed the blood." Any reason to

18 dispute that?

19 A No.

20 Q As a matter of fact, that's what's reflected in the

21 security log, right?

22 MR. KNOTT: Form.

23 A True.

24 BY MR. GENDE:

25 Q Her mattress -- under the security log it says, "Her



Page 154

1 mattress appears to have blood on it," right?

2 A Yes.

3 Q Any reason why your correctional staff didn't call a

4 medical emergency at that time?


6 A You would have to know the totality of the

7 circumstances.

8 BY MR. GENDE:

9 Q Can you explain to me why your correctional staff

10 didn't call a medical emergency at the time they

11 believed they saw blood on Ms. Swayzer's blankets?


13 A Blood doesn't always equal a medical emergency. It

14 could be a menstrual cycle. I'm not there. It's

15 based off of each situation.

16 BY MR. GENDE:

17 Q But I want to talk about this situation, that you were

18 the commander in the jail, that you engaged in post

19 incident inquiries, you communicated with Ms.

20 McCullough, you communicated with your captains. As

21 we sit here today, are you able to tell me why C.O.

22 Witkowiak, when she thought she saw blood on Ms.

23 Swayzer's blankets at 0555, didn't call a medical

24 emergency?

25 A No.



Page 155

1 Q Do you know if C.O. Witkowiak was advised or aware

2 that Ms. Swayzer was pregnant?

3 A Don't know. I don't know.

4 Q Do you think that's something that your correctional

5 staff should have been advised of at the time?

6 A Yes.

7 Q All right. I want to look at Bates 881 of 55A,

8 please. So this was the performance coaching done

9 with Dr. Tulay Gulsen, so I had misspoke earlier in

10 the deposition.

11 A Okay.

12 Q I can go through this sentence by sentence again if

13 you'd like, but I want to ask you if there's any

14 information or evidence you have as we sit here today

15 that Ms. McCullough is incorrectly reporting what's

16 part of her report?


18 MR. KNOTT: Join.

19 A What was the question?

20 BY MR. GENDE:

21 Q You read the full paragraph, right?

22 A Yes.

23 Q As we sit here today, do you have any information that

24 would indicate that what Ms. McCullough is documenting

25 in this report is inaccurate or untruthful?



Page 156

1 A No, not to my knowledge.

2 Q All right. I'd like to move on to the Mortality and

3 Morbidity Review, Bates 883. And the second page of

4 that talks about, "Discuss management and suggestions

5 for alternative strategies or needed improvements."

6 On the last page, 884? It says, "No. 1, Medical. It

7 was stressed to the providers that patients who

8 continuously refuse physical exam may need to be sent

9 out to the hospital for medical clearance." Do you

10 know whether in fact that happened with Ms. Swayzer,

11 that she continued to refuse medical exam?

12 A Do I know if she was sent to the hospital --

13 Q No.

14 A -- for refusing? I don't know what you're asking me.

15 Q That's not my question, ma'am. My question

16 specifically is, do you know whether in fact it was an

17 issue that Ms. Swayzer continued to refuse medical

18 exam, yes or no?

19 MR. SKARPIAK: Form, foundation.

20 A Well, I know, based off of what you just read to me a

21 few minutes ago, that she refused treatment three

22 times in a row, according to this report.

23 BY MR. GENDE:

24 Q Now, as the commander of the jail who is responsible

25 for the health, welfare, and safety of the inmates



Page 157

1 under your supervision and control, in the event that

2 an inmate is refusing medical attention multiple days

3 in a row, do you expect your health care providers to

4 get that inmate to the hospital or not?

5 MR. FRANCKOWIAK: Foundation.

6 A It depends on -- it depends.

7 BY MR. GENDE:

8 Q Well, in this particular case, a late-term pregnant

9 female who was diagnosed with mental health issues who

10 was moved without Medical or Mental Health approval

11 and is refusing medical attention, is that the type of

12 individual that you want your health care providers to

13 get to the hospital?


15 A I can't make their medical determinations.

16 BY MR. GENDE:

17 Q Yeah. But you're the commander of the jail. So as

18 the commander of the jail, I'm asking you, is that the

19 type of inmate that I've just described somebody that

20 you want your health care providers to get to the

21 hospital?

22 MR. RUSSART: Same objections.

23 MR. MEAGHER: Objection. Asked and

24 answered.

25 THE WITNESS: Yeah.



Page 158

1 MR. KNOTT: It's argumentative and beyond

2 the scope of her expertise.

3 MR. GENDE: Not as the commander.

4 MR. KNOTT: No.

5 BY MR. GENDE:

6 Q I'm asking you as the commander, ma'am.

7 MR. KNOTT: You know, an objection isn't a

8 reason to ask the question again, so...

9 BY MR. GENDE:


11 A I think I've answered it.

12 Q Ma'am, you have to answer the question.

13 A I did. I answered it. I said I'm not prepared to --

14 I'm not a medical person and I can't determine who

15 needs to go to the hospital.

16 Q You worked hand-in-hand with Armor to make sure that

17 health care was provided to the inmates under your

18 supervision and control, true?

19 A Yes, I did.

20 Q All right. So considering you worked hand-in-hand

21 with Armor and based on the description that I've

22 provided for Ms. Swayzer where she was refusing

23 medical attention, she was late-term pregnant, she had

24 mental health diagnosis, and she was moved without

25 approval, is that the type of inmate that you as the



Page 159

1 commander want to see taken to a hospital or should

2 she remain under your custody and control?

3 MR. MEAGHER: Objection. Asked and

4 answered.


6 MR. KNOTT: Form.


8 MR. KNOTT: Asked and answered.

9 You can rely on your prior response, or if

10 you have anything to add to it, do so.

11 A I've answered it.

12 MR. GENDE: All right. Let's go off the

13 record.


15 (Off the record)


17 MR. GENDE: So I'd like to call the court

18 based on the objections and direction to the

19 witness on how she should answer. I don't

20 believe that the answer has been provided. I'm

21 seeking clarity of the answer, considering the

22 witness's position as the commander of the jail

23 during the time period in question. If counsel

24 doesn't allow her to answer the question, then

25 I'd like to involve the court and have a



Page 160

1 determination made.

2 MR. KNOTT: Once again I ask, what's wrong

3 with you, Mr. Gende? These were objections that

4 the question was asked and answered. She said

5 she had nothing further to add to it. You're

6 just trying to bully the witness by asking over

7 and over again. She's answered this at least

8 four times.

9 MR. GENDE: So I don't believe that there's

10 been a clear answer provided. There's been

11 multiple objections and I seek clarity. I'm

12 certainly not attempting to bully anybody.

13 MR. KNOTT: And it's --

14 MR. GENDE: But I'm happy to put it in front

15 of the court so the court can make a decision,

16 and either the question has to be answered or the

17 judge can tell me to move on.

18 MR. RUSSART: So why don't you do it in the

19 form of briefing where everybody can --

20 MR. GENDE: Because that takes too long. I

21 don't want to have everybody return here. So in

22 any event, do you want to use your speaker phone

23 that you have in front of us or should I use my

24 iPhone to make the call?

25 MR. KNOTT: For the record, the court did



Page 161

1 specify that there needs to be agreement among

2 counsel before we call the court. This is a

3 petty position by you that we cannot state

4 objections and that you're going to call the

5 court rather than proceed according to the Rules

6 of Civil Procedure. I think it's a patently

7 improper use of the court's generosity for us to

8 have -- there's no direction to the witness not

9 to answer, and that's a misrepresentation. So

10 the rules of procedure say the testimony is taken

11 subject to objections, and that's exactly how

12 we're proceeding.

13 MR. GENDE: I don't believe that the witness

14 has provided the testimony. So there's no

15 requirement that everybody agree to call the

16 court regarding a deposition issue with

17 objections, so I'm going to call Judge Duffin.

18 He's been assigned to handle these type of

19 issues. And can we use your speaker phone or

20 would you like to --

21 MR. KNOTT: We can go off the record. I'm

22 going to make sure that the court reporter has

23 all of the questions cued up.

24 MR. GENDE: Okay.

25 MR. KNOTT: And we can count how many there



Page 162

1 were before we're calling the court.

2 MR. GENDE: Okay. Go ahead.

3 THE REPORTER: All right. Off the record.

4 (Off the record - court called by telephone)


6 MR. GENDE: We've received the court's

7 direction on how to proceed. Mr. Knott has left

8 the room and is consulting with his client. I've

9 asked him not to do that. I wanted to proceed

10 with the questioning that the court allowed and

11 we'll stay on the record until Mr. Knott and his

12 client return.

13 (Mr. Knott enters room)

14 MR. RUSSART: Mr. Knott, you should know

15 that Mr. Gende has made a record without you

16 present. Maybe you want to have it read back to

17 you so you know what was going on in your

18 absence.

19 MR. KNOTT: Mr. Gende, why are we making a

20 record without all the counsel in the room?

21 MR. GENDE: You guys have done it previous

22 in this case. When Mr. Katers and I left, you

23 went on for a long time making a record. And

24 because I felt --

25 MR. KNOTT: You were in the room when --



Page 163

1 MR. GENDE: Let me finish.

2 MR. KNOTT: You walked out of the room.

3 MR. GENDE: You've asked me a question. Let

4 me finish, sir. We went back on the record

5 because I asked you not to consult with your

6 client prior to her answering the question that

7 the judge directed, and you left not only the

8 room, but you left the office space and walked

9 down the hall with your client. So that's -- I

10 want to make that record before we proceed.

11 MR. KNOTT: Well, this is the problem. The

12 judge clearly said you should bring a motion if

13 you have a problem, because he needs to see the

14 context. So I also think the judge was telling

15 us that we should talk to the witness about what

16 she's saying, so...

17 MR. GENDE: Well, I don't think he wanted

18 you to talk to the witness.

19 MR. KNOTT: Well --

20 MR. GENDE: He wanted me to clarify the

21 question.

22 MR. KNOTT: Yeah. You know what? I'm going

23 to do the advising of the client --

24 MR. GENDE: Okay.

25 MR. KNOTT: -- rather than having



Page 164

1 plaintiff's counsel do that, so you have limited

2 right to pursue this, according to the judge, but

3 we're not going to browbeat her with five or six

4 repetitions of this question.

5 BY MR. GENDE:

6 Q So the question as posed, ma'am, is: with you in the

7 position as commander of the jail and understanding

8 that you work hand-in-hand with Armor to make sure

9 that inmates under your supervision and control are

10 getting the appropriate health care, in this

11 particular instance, when Ms. Swayzer was a late-term

12 pregnant female, when she had a diagnosis of mental

13 health issues, where she was moved without the

14 approval of Medical or Mental Health, and where she

15 was refusing medical intervention, as the commander of

16 the jail, is that the type of individual that you want

17 transferred to a hospital or do you prefer that type

18 of individual remain under your supervision and

19 control as a commander?

20 MR. KNOTT: Same objections.

21 BY MR. GENDE:


23 A I would defer to Medical.

24 Q And is that what counsel advised you to say out in the

25 hallway?



Page 165

1 MR. RUSSART: That --

2 A That's my --

3 MR. RUSSART: Oop, oop. That calls for

4 attorney-client privilege, and even though I'm

5 not her attorney, every lawyer in the room knows

6 that. It's an improper question.

7 MR. KNOTT: Yeah. It's unprofessional.

8 It's to be expected, Mr. Gende, I guess. But

9 obviously direct the client not to answer the

10 question.

11 THE REPORTER: Okay. There was a response.

12 Do you remember what it was, because it --

13 MR. RUSSART: She's not going to give it.

14 MR. KNOTT: Yeah.

15 MR. RUSSART: So if you didn't get it on the

16 record, it's not on the record.

17 BY MR. GENDE:

18 Q Okay. So I'd like to show you what we've marked as

19 Exhibit No. 48. This is a criminal complaint against

20 Armor for falsifying records. Are you aware as to

21 whether or not Armor falsified any records in Ms.

22 Swayzer's case?


24 Foundation.

25 A I'm not aware.



Page 166

1 BY MR. GENDE:

2 Q Did you make any attempt to investigate whether or not

3 Armor had falsified records as it relates to Ms.

4 Swayzer?

5 A Again, I'm not the person who does the investigations.

6 Q Right. But as the commander, I'm asking you, did you

7 make any attempt to determine whether or not Armor was

8 falsifying records as it relates to Ms. Swayzer's

9 case?

10 A The investigations would be conducted by the proper

11 people.

12 Q And that didn't include you as part of the chain of

13 command, correct?

14 A No, it does not.

15 Q I'd like to show you what we've marked as Exhibit No.

16 76. Can you describe what that document is for the

17 record?

18 A Looks like a copy of a log or...

19 Q What type of log?

20 A I've been gone for a while. I don't know.

21 Q Do you know what "L/E" means in the correctional

22 context?

23 A Where is it?

24 Q "Late entry"? Is that what it means?

25 A Oh. Yes.



Page 167

1 Q Can you explain why C.O. Cunningham at the time was

2 making late entries for July 6th as it relates to Ms.

3 Swayzer?

4 A No, I cannot.

5 Q Can you explain why Ms. Cunningham was making a late

6 entry for July 7th as it relates to Ms. Swayzer?

7 A No.

8 Q Can you explain why C.O. Cunningham was making a late

9 entry on July 8th as it relates to Ms. Swayzer?

10 A No.

11 Q Can you explain why Ms. Cunningham, or C.O. Cunningham

12 was making a late entry on July 9th as it relates to

13 Ms. Swayzer?

14 A No.

15 Q Did you make any attempt as the commander to review

16 this document after the baby died and determine why

17 somebody under your supervision and control was making

18 a multitude of late entries as it relates to Ms.

19 Swayzer?

20 MR. KNOTT: Form.

21 A There were detectives assigned to investigate the

22 case.

23 BY MR. GENDE:

24 Q Were those detectives the commander of C.O. Cunningham

25 at the time?



Page 168

1 MR. KNOTT: Argumentative.

2 A No.

3 BY MR. GENDE:

4 Q Who was her commander at the time?

5 A I was.

6 Q And considering you were the commander at the time

7 that Ms. Cunningham, C.O. Cunningham at the time, was

8 making these late entries, can you explain why you

9 didn't ask her the purpose of these multitude of late

10 entries after Ms. Swayzer's baby died?

11 A Sure. Because there was an investigation in progress

12 and I don't interfere with that.

13 Q I want to show you what we've marked as Exhibit No.

14 27, which is a series of documents from

15 Classification. Do you know what a classification

16 notice is?

17 A A classification notice?

18 Q Do you know what that is?

19 A No. What is it?

20 Q Well, the first page says, "Classification Notice," at

21 the top of it.

22 A Okay.

23 Q All right. Do you know what a classification notice

24 is?

25 A Yes.



Page 169

1 Q And how do you know what a classification notice is?

2 A From my -- now seeing it, I remember what it is.

3 Q Okay. And what's the purpose of a classification

4 notice?

5 A To appropriately classify and house inmates.

6 Q And do you know how C.O. Cunningham was trained to

7 complete these classification notices back in July of

8 2016 before Ms. Swayzer's baby died?

9 A I might have to consult with the Training Academy who

10 conducts the training.

11 Q Were you ever trained on how to complete a

12 classification notice?

13 A I didn't work classification.

14 Q So the answer would be no?

15 A Correct.

16 Q And you're unable to tell me as we sit here today how

17 Ms. -- I'm sorry -- C.O. Cunningham was trained on

18 completing a classification notice.

19 A Correct. Training Division is responsible for

20 training.

21 Q Do you know when the classification notice is supposed

22 to be completed?


24 A When they enter the jail.

25 BY MR. GENDE:



Page 170

1 Q And why is that?

2 A To appropriately house the inmate.

3 Q And that's the policy and procedure in place while you

4 were the commander, that when an inmate enters the

5 jail, a classification notice like what we've marked

6 as Exhibit No. 27 should be completed, right?

7 MR. KNOTT: Object. Overly broad and vague.

8 A To the best of my recollection, yes.

9 BY MR. GENDE:

10 Q And that's to ensure that the inmate, when they come

11 into the jail, is appropriately housed, correct?

12 A Yes.

13 Q Is this something that Security is responsible for

14 completing or Correctional or Medical?

15 A Security does this portion.

16 Q And because it's a classification notice, you expect

17 the classification officer to complete it, true?

18 A Yes.

19 Q They're the ones that receive the training to do a

20 classification notice when the inmate comes into the

21 institution, true?

22 A Yes.

23 Q And we can see that when Ms. Swayzer came in to the

24 institution in April of 2016, a classification notice

25 was done, correct?



Page 171

1 A Yes.

2 Q We can see on the next page that when Ms. Swayzer came

3 back to the institution on July 16th, 2016, after she

4 lost her baby, a classification notice was done,

5 correct?

6 A Yes.

7 Q And those were both requirements because she was

8 entering the institution.

9 A Yes.

10 Q Right? I can tell you that there was no

11 classification notice that's been provided to us in

12 discovery that was completed for Ms. Swayzer when she

13 entered the facility on July 7th, 2016. Are you able

14 to explain as the commander why Cunningham failed to

15 do that classification notice on July 7th, 2016?

16 A No.


18 Exhibit No. 77. Do you recognize T. Cunningham's

19 signature on the first page of that document?

20 A Yes.

21 Q Do you understand what a "Classification Maximum

22 Protective Custody Status Report" is?

23 A Yes.

24 Q What's the purpose of that report, ma'am?

25 A To properly classify an inmate.



Page 172

1 Q And that's something that's to be competed upon the

2 entry of the inmate to the institution, correct?

3 A Yes.

4 Q Along with the classification notice, right?

5 A Yes.

6 MR. KNOTT: Object to form --

7 BY MR. GENDE:

8 Q And then the tier card --

9 MR. KNOTT: -- foundation.

10 MR. GENDE: I'm sorry.

11 Q And then the tier card is filled out in addition to

12 the classification and classification notice, right?

13 A Yes.

14 Q And that's all upon entry of the inmate to the

15 institution, correct?

16 A Yes.

17 Q So as part of Exhibit 77, we have Bates 155, the

18 Maximum Protective Custody Status Report, and Exhibit

19 No. 156 is the July 16th classification notice, right?

20 A Yes.

21 Q So one Bates stamp later, but we don't have one for

22 July 7th, right?


24 A Yes.

25 BY MR. GENDE:



Page 173

1 Q So considering C.O. Cunningham failed to follow policy

2 and procedure in completing a classification notice on

3 July 7th, 2016, can you identify how Ms. Swayzer was

4 then properly housed without that notice?


6 Argumentative, foundation.

7 BY MR. GENDE:

8 Q Can you explain that, ma'am?

9 A No.


11 Exhibit No. 36 at former Sheriff Clarke's deposition.

12 These are a series of policies and procedures that

13 were provided by the county that were in effect back

14 when Ms. Swayzer lost her baby. Are you familiar with

15 these policies and procedures?

16 A Yes.

17 Q And in particular, the first one is "409, Detention

18 Services Bureau Inmate Health Screening," and there's

19 a "Purpose" underneath that "Inmate Health Screening,"

20 correct?

21 A Yes.

22 Q Do you know whether C.O. Cunningham was trained in

23 this policy and procedure?

24 A Yes.

25 Q How do you know that?



Page 174

1 A The officers, when I was there, had signed off to

2 knowledge of all the policies and procedures.

3 Q Under "Policy" it says, "All inmates in the MCJ shall

4 have unfettered access to medical, dental, and mental

5 health care." Was that in fact the policy in effect

6 when Ms. Swayzer lost her baby in July of 2016?

7 A Yes.

8 Q And that would include the unborn child for a pregnant

9 female, true?

10 A Yes.

11 Q And why is that? Why are all inmates, including their

12 unborn children, entitled to unfettered access to

13 medical, dental, and mental health care while at the

14 Criminal Justice Facility?

15 MR. KNOTT: Object. Form, vague, overly

16 broad.

17 A Yeah. Could you repeat the question, please?

18 BY MR. GENDE:

19 Q Well, we know what the policy is, and I'm asking what

20 the underlying purpose is to include unborn children

21 having the same entitlement to unfettered access to

22 medical, dental, and mental health care.

23 MR. KNOTT: So the question is about unborn

24 children?

25 BY MR. GENDE:



Page 175

1 Q What's the purpose behind the policy as it relates to

2 unborn children? That's the question.

3 A Well, there's no particular policy on unborn children.

4 The policy relates to anybody in the facility.

5 Q So that includes unborn children. We've established

6 that. In the event that the mother is refusing care

7 for herself, what was the policy and procedure in

8 place to take care of the unborn child back when Ms.

9 Swayzer was incarcerated in July of 2016?

10 A That she would be seen by the medical staff who would

11 make decisions on her medical treatment.

12 Q Right. But in the event that she's refusing the

13 medical treatment, what policy and procedure was in

14 place by Milwaukee County to ensure that the unborn

15 child had unfettered access to medical, dental, and

16 mental health care?

17 MR. KNOTT: Form.

18 MS. MEAGHER: Foundation.

19 A This is the policy.

20 BY MR. GENDE:

21 Q Right. But you told me it doesn't refer to unborn

22 children, so I'm wondering if there's one that you can

23 train or trained your people on, when an inmate like

24 Ms. Swayzer is refusing medical care, how that unborn

25 child gets the medical care that it's entitled to?



Page 176

1 Unfettered access to medical, dental, and mental

2 health care, what's the policy and procedure in that

3 regard?

4 MR. SKARPIAK: Form, argumentative.

5 A Yeah. The policy is to have medical staff available

6 to care for the inmates and to make medical decisions

7 regarding their treatment.

8 BY MR. GENDE:

9 Q I understand the policy, and we've gone over that in

10 409. But how is that policy enforced as it relates to

11 unborn children?


13 BY MR. GENDE:

14 Q You can tell me.

15 MR. KNOTT: It's argumentative.

16 A We don't have policies for -- specifically for unborn

17 children. That's the -- I can't add anything to that

18 answer.

19 MR. GENDE: Okay. So I think I'm done. I'm

20 going to have a quick conversation with co-

21 counsel and we'll let you know if we have any

22 other questions.


24 (Off the record)




Page 177

1 BY MR. GENDE:

2 Q Has the policy and procedure been changed to include

3 the care of unborn children while in custody?

4 A I don't know.

5 Q Did it change while you were the commander?

6 A No, it did not.

7 Q What totality of circumstances training did your

8 people receive while you were the commander at the

9 jail?

10 MR. KNOTT: Form.


12 BY MR. GENDE:

13 Q So when you've said "totality of the circumstances,"

14 that your correctional staff in order to make

15 decisions about movement without Medical or Mental

16 Health approval are to consider the totality of the

17 circumstances, you can't tell me what training any of

18 them received in that regard?

19 MR. KNOTT: It was already -- she already

20 asked -- answered that question, but...

21 MR. GENDE: Well, you objected, so I

22 clarified it.

23 A The Training Division conducts the training.

24 Q But I'm asking you as the commander. Do you know how

25 your people were trained during the time period you



Page 178

1 were the commander when Ms. Swayzer's baby died in

2 understanding the totality of the circumstances when

3 moving an individual from Special Needs Unit to

4 overflow in 4A without Medical or Mental Health

5 approval?


7 A No.

8 BY MR. GENDE:

9 Q Finally, as far as exigent circumstances are

10 concerned, you've previously described that situation

11 at this deposition. Can you tell me how your

12 correctional staff while you were the commander were

13 trained to recognize exigent circumstances regarding

14 the move of an individual from the Special Needs Unit

15 to overflow without Mental or -- Medical or Mental

16 Health approval?

17 A They received training at the Training Academy, and I

18 can't, without looking at the records, speak of that

19 at this time.

20 MR. GENDE: Okay. I have nothing further.

21 THE REPORTER: All right. Let's go off the

22 record briefly.

23 (Off the record)

24 THE REPORTER: Back on the record. Mr.

25 Russart.



Page 179


2 BY MR. RUSSART:

3 Q Ms. Evans, could you find Exhibit 126 in the pile of

4 exhibits that you've been given? It's the most --

5 it's the recent Milwaukee County audit. Do you have

6 that?

7 A Yes.

8 Q Can you tell the group here whether that's a complete

9 copy of the audit? Look at the table of contents

10 there.

11 A Okay. Page 110. No, it does not.

12 Q Okay. What's the last page in the document? What's

13 the page number?

14 A Six.

15 MR. RUSSART: Okay. That's all that I have.

16 THE REPORTER: Okay.

17 MR. KNOTT: Anything further based on that?

18 MR. GENDE: Yeah.


20 BY MR. GENDE:

21 Q So when I provided you with a copy of 126, what you

22 received was the letter from the auditor, and then you

23 received the background overall objective, what we

24 found, the table of contents, and the summary of the

25 report's findings, true?



Page 180


2 MR. GENDE: Following up on Mr. Russart's

3 questions.

4 A Letter, background, overall objective, summary.

5 Q And table of contents, right, listing the table of

6 contents?

7 A And the table of contents, yes.

8 MR. GENDE: Excellent. Thank you, ma'am.

9 MR. RUSSART: All right. One more question.

10 THE REPORTER: Go ahead. Mr. Russart.

11 MR. RUSSART: Yeah.


13 BY MR. RUSSART:

14 Q Do you know whether or not the summary is complete?

15 MR. GENDE: Objection. Calls for

16 speculation, foundation.

17 A I don't know.

18 MR. RUSSART: Okay. Thanks.

19 MR. KNOTT: I have a clarification.

20 THE REPORTER: Mr. Knott.

21 MR. KNOTT: Yeah.


23 BY MR. KNOTT:

24 Q Ms. Evans, you have never seen any of the reports

25 filled out by the officers or the recorded statements



Page 181

1 by the detectives that investigated the Swayzer

2 incident, true?

3 MR. GENDE: Objection. Compound, leading.

4 A True.

5 BY MR. KNOTT:

6 Q So you've never seen any statement by Kim Witkowiak as

7 to her thoughts and observations that evening, true?

8 A True.

9 MR. GENDE: Objection. Leading.

10 BY MR. KNOTT:

11 Q And why is it that you would not have seen that?

12 A Because Internal Affairs conducts the investigation.

13 I'm not in that department, so I wouldn't have that

14 information.

15 Q And Mr. Gende asked you questions about the timeliness

16 of the call for a medical emergency. I want you to

17 assume that Ms. Witkowiak believed that the -- that

18 Ms. Swayzer was acting bizarrely, and when she was

19 asked, she said, "I'm fine. I'm just sleepy." Would

20 it be reasonable for the correctional officer in that

21 circumstance to investigate further by making a call

22 to the Medical department?

23 MR. GENDE: Objection --

24 A Yes.

25 MR. GENDE: -- foundation. Calls for



Page 182

1 speculation. Outside the scope --

2 MR. KNOTT: Hmm.

3 MR. GENDE: -- of the witness's expertise.

4 MR. KNOTT: I guess it wasn't beyond her

5 expertise when you asked the question, but...

6 MR. GENDE: I'm making my legal objections,

7 Counsel. You don't have to -- you don't have to

8 --

9 MR. KNOTT: Those are the questions I have.

10 Thank you.

11 THE REPORTER: Okay. There being no further

12 questions, the deposition is concluded at 2:25

13 p.m. Off the record.



Page 1

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called 15:7 16:2427:20 105:3131:10,13 132:4133:1,6,14,18135:5,9 136:7136:24 138:1147:10 162:4

calling 11:11137:17 146:18162:1

calls 25:25 64:2190:23 97:7137:21 165:3180:15 181:25

Cameras 69:18capacity 13:20

14:10 15:21captain 16:2,3,9

16:11 17:1,7,1617:23 18:9,1335:18,19,1947:12 94:20123:5 127:3,15

captains 16:1234:21,24 35:135:10,16,22,2536:1,14,2238:10 39:945:21 53:2466:22 94:13126:17 146:14154:20

card 44:15 45:245:15 47:1,951:9,14 52:2056:4,23 58:6,1359:17 61:7,2362:2,11,17,2164:7,25 65:7,1066:11 67:6 83:2123:10 172:8,11

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coaching 155:8collaboration

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competed 172:1complaint 165:19complaints 130:8complete 47:16

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Compound 181:3Comptroller

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concerns 95:2496:1 102:8115:16 116:17

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consulting 162:8contacts 27:7contain 136:13contained 24:24

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contents 150:3,18150:24 151:11179:9,24 180:5180:6,7

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conversations 7:711:20,23 22:2225:17,23 26:326:12 34:935:12 36:13,1938:16 85:5,894:9,10,14100:13,16 108:7109:3 126:18,19

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correctional/sec...63:18

Corrections 13:1113:15,18 14:1015:19 18:2119:13 24:9

corrective 139:6139:10 143:4145:14,23

correctly 35:1846:10

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Page 6

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disputes 150:24151:11

distress 151:20152:22,24 153:1153:3

District 1:12,13division 4:11 28:9

30:24,25 58:22



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Page 8

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fine 37:4 181:19finish 163:1,4

finished 13:12,1317:3 138:25

first 6:15 9:2,109:11 10:1 13:913:14 14:116:12 17:12,1627:18 36:2,2037:11 55:2356:19 102:20108:11 129:6,13139:13 140:9149:8,13 168:20171:19 173:17

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forwarding 8:1412:7 20:12,24



Page 9

76:17found 6:5,11

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four 78:25 121:18122:21 139:14160:8

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19:1 38:6 70:21133:7 160:5178:20 179:17181:21 182:11

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F-o-l-l-i-a-r-d103:5

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4:12,13 7:10 8:48:10 10:21 11:111:5,9,13 21:2422:8,10,14,20,2423:1,6 27:6 28:228:24 29:14,2030:8,16 31:932:14 39:1,6,1539:21 40:6,1840:25 41:3,6,1141:17 42:1245:18 46:2248:11 49:8,1449:19 50:2,1350:19 51:4,2452:9,18 53:357:15,17,20

58:16,25 59:4,559:13,24 60:1260:19 61:4,1862:6 64:10,2366:14 67:10,2070:11 71:2572:2,5,8,10,1372:14,20 73:4,874:2,6,14,23,2575:6,10 77:1,977:17 78:3 81:681:13,18,2582:4 85:2,1286:6 89:2 90:191:2,21,25 92:893:18 94:2496:12,24 97:1097:23 98:3,11102:13 103:4,16105:24 106:5,22107:5,13,17,24108:8,19 109:7109:20 110:9,19111:5,9,18,24112:9 113:1,13113:17 114:6,25115:7,11,23116:11,16,22117:1,12,20119:13 120:1,23121:6 122:9123:17,21 125:8128:22 129:12133:10,21134:18 135:2,20137:3,15 138:2138:15 140:3,8140:17 141:10141:19 142:5,11142:22,23 143:2143:10,14,20144:2,5,23147:6 148:22149:1,7 150:8150:12,17 151:7152:6 153:10,24

154:8,16 155:20156:23 157:7,16158:3,5,9159:12,17 160:3160:9,14,20161:13,24 162:2162:6,15,19,21163:1,3,17,20,24164:5,21 165:8165:17 166:1167:23 168:3169:25 170:9172:7,10,25173:7 174:18,25175:20 176:8,13176:19 177:1,12177:21 178:8,20179:18,20 180:2180:8,15 181:3181:9,15,23,25182:3,6

Gendelman 3:8general 24:23generalize 25:10generally 22:1

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generate 5:2023:16

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122:12 136:8164:10

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27:15 37:344:22 46:952:24 70:7,1584:14 129:15151:2 165:13

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83:8 84:1485:24 86:7,18106:15 124:14132:12 153:16

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Gold 35:19,22good 11:24 55:18



Page 10

100:5gotten 13:10 70:2graduated 19:17

19:24grounds 10:18

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guard 133:4,16guards 132:24guess 26:16,22

165:8 182:4Gulsen 3:18

138:11,20 155:9Gulsen's 138:17guys 162:21

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53:18 121:7,9121:11

handpick 53:17handwritten

57:22hand-in-hand

158:16,20 164:8happen 27:16happened 17:20

63:16 71:2272:21 135:19,21137:4 156:10

happy 41:22113:20 117:14160:14

harm 63:3head 5:5 28:11

98:24health 2:24 3:24

33:15 37:1938:19 42:5,9

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hear 119:9heard 102:3help 135:19 136:7

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89:7 125:19Hmm 182:2

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123:8 125:18home 7:24 17:21honor 21:21Horton 4:10

38:17 42:1948:25 49:7 52:452:11 67:1487:17,24 88:1388:17,18,2489:22 90:1496:18,19

hospital 73:13134:11,20135:15 156:9,12157:4,13,21158:15 159:1164:17

hour 9:25 10:773:3 128:18

hours 10:7 101:18114:20 115:3,15

house 13:11,15,1714:10 15:1816:18 18:4,1118:21 19:1324:9 59:1 62:1118:11 169:5170:2

housed 36:16 40:546:17 70:1371:14,23 124:11125:23 126:2170:11 173:4

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HR 53:20hypothetical

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6:13 33:9 44:1684:3 89:19102:24 107:10136:6

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31:21,23 32:1963:3 136:23

implemented51:17

importance145:18 146:9

important 8:1821:1,2 96:23133:24

improper 72:16161:7 165:6

improve 108:5146:2

improvements156:5

inaccurate 41:679:12 123:20155:25

inadequate107:21

incarcerated175:9

incident 31:1050:5 57:7 129:2154:19 181:2

include 21:2022:2 73:15 93:8102:4 106:16166:12 174:8,20177:2

included 14:2273:14 116:12

includes 113:16114:19 115:14175:5

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Incomplete136:25 137:13

incorrect 59:7incorrectly

155:15increase 97:15

101:16 109:2increased 108:13independent

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92:24 105:4,10132:20,21155:24

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indicating 79:22145:7

indication 86:7indicator 140:10

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47:25 48:6,1849:22 65:1783:22 127:10,11157:12 164:16164:18 178:3,14

individuals 25:1534:19 35:1153:16 85:22125:23 126:2,7128:8 138:22

individual's 49:10infant 139:7

147:22 148:1,3infirmary 37:5,6

37:9,14 38:2239:11 40:8



Page 11

41:14,25 42:2,342:23 45:23

infirmary/Special38:2

information 7:228:20 23:15,1623:18,20,2424:1,19,21,2325:3 27:3,1835:6 36:21 37:438:11 39:1043:11 45:7,958:20,23 59:260:7,13,17 61:662:16 64:6,1264:18 65:1,866:17,19 67:467:23 68:4,1868:22 69:3,5,1169:11,24 70:2170:22 71:1,9,1773:16,20,2176:12,17 78:1383:2,7 86:2088:22 90:11,1491:1,15 99:24112:15 114:4,21122:3 123:9128:2 129:3,16129:18 135:12136:8,14 141:11145:13 150:20150:23 155:14155:23 181:14

informed 140:21152:14 153:13

informing 145:18146:9

inhibit 144:16initial 66:4initially 13:20

98:13initiate 27:7 51:17initiated 67:14

126:21 148:10inmate 45:5 46:9

47:6,25 48:1551:18 64:1788:25 110:7118:5 125:13133:3 136:20149:11,16,17152:12 157:2,4157:19 158:25170:2,4,10,20171:25 172:2,14173:18,19175:23

inmates 21:1522:3 25:8 33:1545:6,8 66:8 97:299:18,19,20109:11,14 110:1110:5,23 112:4112:16,18 113:2115:18 117:6119:16 120:20121:20 124:2,6125:11,15 134:3134:7 152:21156:25 158:17164:9 169:5174:3,11 176:6

inmate's 45:347:9,20 56:2364:6

inquire 11:1237:8 132:15

inquired 36:1642:24

inquiries 130:14154:19

inquiring 67:2368:3 128:5

inquiry 36:1773:17 75:1479:16 84:12,17130:18

inspection 95:15152:21

inspections 31:2432:7,23 33:2,19

132:22inspector 16:24

17:14,22 18:719:2,11 20:424:6,10,14,1625:14,18,23,2526:3 27:2,11,1127:14,17,1828:8,10 35:1,236:7,15,15,2238:10 39:945:22 53:2254:8 55:6 68:468:10,13 95:4100:3,16 101:23102:14 104:13105:3,10 131:21131:24

Inspectors 26:6instance 24:25

164:11institute 145:22institution 170:21

170:24 171:3,8172:2,15

instructed 113:18148:10

instruction 11:3,467:1

instructions 62:10Insurance 3:24intake 47:17intend 11:12intending 30:6interaction 20:5

55:15 83:9127:4

interesting 91:14interfere 168:12interfering

131:14interim 6:24

116:19 117:15internal 23:19

25:5 27:25 28:830:25 56:12

66:4 132:9138:25 181:12

intervention164:15

interview 15:116:22 17:1457:23,24 58:4,658:13 59:1260:14

interviewed 58:2159:22 60:1

introduction103:1

invades 10:18investigate 27:21

27:24 28:4 32:370:23 166:2167:21 181:21

investigated181:1

investigating56:13,14 80:2080:22 131:16

investigation 28:728:9,11 30:2431:3,8,10 50:650:11 56:12,1256:18 73:16129:2 131:15,25132:5 136:18139:4 150:22168:11 181:12

investigations25:5 56:7 65:2566:2,2 166:5,10

involve 21:1523:10,13 159:25

involved 12:2020:8 31:10 86:988:8

involvement 4:2029:2,2 96:6138:17 139:3

in-custody 5:2523:10,12 24:127:8 28:15 29:6

30:18in-person 10:4iPhone 160:24issue 28:18 33:4

34:7,18 36:843:12,18 46:1350:18,20 63:1363:13 81:12,1581:20,21 82:985:1 97:1699:14,15,21100:11,12101:24 102:1105:22 109:10110:4 111:14112:1 116:8,15117:10 126:13128:11 132:20140:12,19142:16 152:15156:17 161:16

issues 14:24,2526:9 32:5,2233:19,25 34:234:11 42:5,945:25 46:2,580:21 97:1299:11,12 100:2100:7,9,14102:3,5,16,19103:23 107:8118:19 126:4157:9 161:19164:13

JJ 2:2,8 3:7jail 12:18,21

23:14 27:1028:14 31:2032:2,20 38:2139:7 43:25 45:448:13 53:8,9,1153:19 54:15,2155:24 56:2,2158:2 61:12,25



Page 12

63:23 65:2266:6 68:23 69:469:14,23 70:470:18,21 72:2573:23 74:7,1075:20 80:2381:7,16,2283:12 86:1389:4 90:17,1990:25 91:392:21 94:2095:1,3,18 96:797:1,13,18 98:598:10,12,23,2599:1,5,8,13,1599:17,21 100:2100:9,15,18,21101:1,7,11,16,19101:22,24 102:8102:15,22 103:8103:10,21,22104:8 105:5,14105:18 106:19107:1 108:21109:22 113:3,7113:22 117:2,15118:2 120:3,5120:15 128:4129:22,23 131:2131:5,11,17,20132:20,21 134:8135:24 136:1,2136:12 141:22142:6,16 143:22154:18 156:24157:17,18159:22 164:7,16169:24 170:5,11177:9

James 2:2 29:730:2 41:2 81:23

Janet 35:19January 15:20

18:7,16,17Jason 3:7Jeff 1:4

Jennifer 103:5job 13:9 27:12

100:5,23 113:5113:24 114:8

Joe 49:7Johnson 3:8Join 46:20 48:9

50:12,25 61:293:15 96:22116:24 123:16144:1 155:18

joint 93:16Joseph 1:4Journal/Sentinel

103:20judge 2:9 160:17

161:17 163:7,12163:14 164:2

July 12:17 35:1766:9 67:22 68:472:6 73:1075:23 78:12,1478:19 85:1586:22 88:1889:4 90:16 91:6120:15 121:16125:23 126:3,3127:19 167:2,6167:9,12 169:7171:3,13,15172:19,22 173:3174:6 175:9

Justice 4:21 19:1422:3 24:10 36:295:7 174:14

KK 59:1Kahn 3:21Karen 3:11Katers 2:9 162:22Katherine 3:17Kayla 12:16

31:13 34:9,1736:13 38:1642:20,21 43:7

68:18 71:1074:19 79:20,2184:22 96:18,19138:11 146:7,24

Kayla's 70:20Kaziah 34:13

83:21keep 5:10 7:19

8:17 24:4 69:7152:1,2

kept 69:19Kevin 35:3key 106:16keyed 92:12Kim 181:6kind 33:8knew 37:11 38:1,1

80:3 128:2Knott 1:6 2:14,15

4:5 7:4,22 8:79:1,3,7,14,1610:9,14,17,2411:14 21:1622:5,9,12,18,2122:25 23:226:20 28:1,1629:7,18 30:1,1431:4 32:1038:24 39:3,1439:17 40:2,1040:23 41:2,4,641:10,13 45:1750:10 51:2353:1 57:13,1657:18 58:14,2359:3,9,18 60:960:16 61:1662:4 64:9,2066:12 67:9 70:971:24 72:4,7,972:12,16 73:273:25 74:5,1274:22,24 75:2,976:24 77:6,1477:23 81:1,1081:17,23 82:2

85:1 89:2490:22 91:18,2294:22 97:7,2198:9 103:13105:21 106:3107:3,15 109:4109:6,17 110:16110:25 112:8,21112:23 113:9,15114:2 115:21116:24 119:4,6119:11,20,23120:18 121:4122:6 123:14,19125:3 128:17133:8,19 134:16134:25 135:17136:25 137:11137:13,24139:24 140:6,15140:23 141:1,4141:7 142:2,18142:23 143:13143:16 144:1,20147:3 148:20,23148:25 149:4150:6,10,13151:5,24 153:22154:5,12 155:18158:1,4,7 159:6159:8 160:2,13160:25 161:21161:25 162:7,11162:13,14,19,25163:2,11,19,22163:25 164:20165:7,14 167:20168:1 169:23170:7 172:6,9172:23 173:5174:15,23175:17 176:12176:15 177:10177:19 178:6179:17 180:19180:20,21,23

181:5,10 182:2182:4,9

know 17:10 21:2322:1 23:2 29:429:14 37:5,1339:19 41:542:20 49:550:22 51:5,1051:11 53:4 55:955:10,14,19,2155:22 57:5,1258:15 59:1163:25 64:1,1265:15 68:10,1269:4 71:2272:18,21 74:1674:19 81:483:20 84:1,4,2186:9 90:2 94:19102:21 103:5107:9 113:2116:2,9,12119:17 120:7,19121:7,8 122:1,3124:9 125:6,20127:2,5,15,17129:10,18130:12 131:24134:14,23 135:8135:21 136:9,11137:17,21 140:5140:7,16 144:7145:12 149:2151:17 152:23154:6 155:1,3,3156:10,12,14,16156:20 158:7162:14,17163:22 166:20166:21 168:15168:18,23 169:1169:6,21 173:22173:25 174:19176:21 177:4,24180:14,17

knowledge 8:8



Page 13

43:22,23,2444:1 60:17,2060:21 117:22136:15 156:1174:2

known 37:14 94:8124:25

knows 165:5

Llack 29:2 34:3

43:15 46:1596:20 102:9108:4 111:14138:17 145:2

lacks 149:4Lang 2:8,9late 40:14 54:17

56:3,23 58:2059:17 60:8,1462:17 118:18166:24 167:2,5167:8,12,18168:8,9

lateral 101:9,10104:23

late-term 39:1839:24 42:4,863:19 64:3,1765:3,9,17 66:967:4 83:3125:24 126:4157:8 158:23164:11

Law 2:3lawyer 165:5lay 113:20lead 28:7leadership 139:16

139:17,18 140:4leading 181:3,9learned 42:25leave 8:22 15:11

15:13,19 54:1493:6 126:8130:21

leaving 10:12,1554:20 136:19

left 17:3 55:2456:21 68:1671:4 162:7,22163:7,8

legal 22:22 27:472:10,15 148:22182:6

Leib 1:6 2:15letter 179:22

180:4let's 11:5 12:25

22:10 29:1741:15 61:21,2262:4 84:8 108:9124:24 127:18129:6 139:6142:12 159:12178:21

level 24:13 82:9106:10 108:12108:14 109:2114:19,19 115:4117:5 122:11,13

levels 96:23 97:498:7 102:17,20106:15 114:16115:1

Liability 3:24lieutenant 14:6,9

15:15,22 34:1034:15 47:1353:5,13,1754:19 83:2185:16 123:4,5,7123:24 126:12126:16,23127:10,11,14,19128:5

lieutenants 14:1214:12 126:19

limited 63:5,17164:1

Linda 3:1line 47:22 76:1,4

89:23lines 82:21,22list 53:20listing 180:5little 5:18 12:25

15:17 44:1756:17 71:12141:3

LLC 1:6 2:9,153:2

located 148:7log 69:4 90:17,19

90:25 91:3129:22,24131:11 132:20132:21 136:12136:13 151:21151:22 152:5,8152:9,10,25153:21,25166:18,19

logbook 64:16,1864:24 65:4,6,6

logged 92:9,14logs 68:23 69:14

70:21 71:873:23 74:1094:20 95:1,3135:24 136:1,2

long 9:24 10:215:10 37:1 44:169:19 98:1,1298:17 101:3,4,5101:14 147:4160:20 162:23

longer 139:5look 8:1 23:25

57:6 68:23,2569:13,14 71:1078:22 84:887:21 88:5 89:698:1 102:23108:9 114:14122:25 125:10125:18 127:18128:15,23 130:3

144:12,13147:22 151:21151:22 155:7179:9

looked 6:4,2356:19 70:20

looking 18:125:10 26:24,2537:12 65:1768:14 71:273:12 76:1688:8 106:6122:3 127:8136:9,11 139:13152:17,18178:18

looks 75:24 87:3166:18

loss 85:2,9lost 39:8 86:13

88:15 89:17121:17 171:4173:14 174:6

lot 102:2loud 140:24Love 34:13 83:21

84:3lower 106:17

114:19L/E 166:21

MM 3:13 4:15 179:1

179:19 180:12180:22

major 17:2518:10,14 76:1084:12

making 42:1456:22 66:17123:12 125:1,16162:19,23 167:2167:5,8,12,17168:8 181:21182:6

management

13:10 156:4manager 14:16,20

15:1,6,10 16:4manner 4:24 5:4

33:13March 94:20mark 6:17marked 5:15 7:17

7:17 11:15 44:344:18,25 45:1661:24 78:189:20 102:25117:24 165:18166:15 168:13170:5 171:17173:10

Master 71:7maternity 15:19matter 20:23

21:19,21 22:1322:15 28:19,2229:3 30:18 44:4153:20

matters 28:23mattress 153:25

154:1Maureen 3:17Max 45:11Maximum 171:21

172:18Mayer 17:25ma'am 4:16 5:14

7:11 8:5,8 14:1516:9 24:1730:13 39:2 57:473:9 75:8,1478:4 92:2105:16 110:20111:6 112:10113:3 115:24123:22 128:23134:12 143:21145:4 149:2152:1 156:15158:6,12 164:6171:24 173:8



Page 14

180:8McCullough

12:16 31:13,1932:16 33:2134:17 36:2337:23 50:767:23 68:3,1168:18,22 70:2571:18 73:1076:12 78:11,1478:18 83:884:18 85:8,1485:24 86:7,1886:22 87:5,1887:23 93:1394:1,17 127:5128:1 138:11,16146:24 147:1149:14 152:7154:20 155:15155:24

McCullough's80:10 84:12149:9 150:25153:16

MCJ 174:3Meagher 3:1

50:24 91:21,24143:25 157:23159:3 175:18

mean 21:2 22:1922:21 31:2332:25 33:12,1358:2 76:3 79:179:16 86:1292:22 99:15104:13 117:9127:14 129:1132:7 144:7

meaning 63:279:18 93:1699:18

means 86:10,1487:14 93:5166:21,24

med 69:10,10

89:22 90:15,1990:24 91:4129:15 152:15152:16

Medial 87:13medical 12:19,21

12:24 15:1332:1,8 33:6,2434:3 37:15,2438:2,14 39:2040:17,21 42:1542:17,18,21,2543:1,2,8 46:3,846:15,24 47:547:16,23,23,2549:21 51:1652:12 60:22,2462:21,24 63:1366:16,25 68:1469:2,7,7,11,1269:13,15 70:2270:23 71:3,1973:15 74:1779:3,6,7,18,2079:22 80:11,1782:23 83:2486:8,14,15,2387:14,21 88:689:3,7 93:12,1693:19,22 94:294:11,15 102:4117:5 121:21122:1,5,12125:15,18126:21 130:16130:23,25 131:9131:13 132:3,17132:25 133:6,14133:17,23 135:5135:5,9,12,18136:3,16,23137:8,17,22138:1,3 140:10140:21,21,22141:8 143:17,18144:9,11,16

146:9,16,17147:9 154:4,10154:13,23 156:6156:9,11,17157:2,10,11,15158:14,23164:14,15,23170:14 174:4,13174:22 175:10175:11,13,15,24175:25 176:1,5176:6 177:15178:4,15 181:16181:22

Medical's 47:1051:20

Medical/Mental83:11 86:8145:19

medication 88:888:14,24 89:189:12 93:6

medications92:25

meds 91:16 92:4,592:6 93:4,5

meet 10:9 108:11109:12,24145:17 146:4

meeting 9:10,149:16,19,22,2410:1,4,6 90:6

meetings 20:9108:2,4 109:23111:13,19,25112:13 146:6

Meine 3:17 48:2059:1 62:1 67:14123:11

member 86:9members 110:7memo 55:2men 120:10menstrual 154:14mental 37:19

38:19 42:5,9

43:3,9,13,16,1743:20 49:2163:15 66:2568:15 69:2,1571:3,19 79:7,1879:20,22 80:1180:17 82:2383:3,24 86:2387:14 89:793:12,16,2294:2,15 102:4112:17 118:19121:18,22122:15 125:15126:4,22 142:14142:24 144:17145:8 146:9,16146:17 157:9,10158:24 164:12164:14 174:4,13174:22 175:16176:1 177:15178:4,15,15

mentioned 33:435:10

met 9:7 10:1184:21 107:7,9108:25

Meyer 3:14MHU 37:20 43:13

59:1 62:1 75:2584:14 85:18,2587:16 94:4142:14,25 145:8

Michael 2:20Michigan 3:22middle 62:14Milwaukee 1:7,8

2:11,16,17,18,233:4,23 4:20 6:18:12,22 19:3,1445:4 103:1,21106:7,12 175:14179:5

mind 112:3minimum 106:10

108:12minutes 10:3

86:24 147:18156:21

Mischaracterizes42:11 46:19

mislead 41:1672:12

misrepresentati...161:9

misspoke 94:25104:3 146:21155:9

Misstates 38:2441:2 123:14

misstating 40:1041:4,13

moment 63:4129:13

moments 58:17Monday 9:20

17:19monitor 95:7monitoring 96:2month 9:11,13months 15:14

18:17 19:18,2157:10 98:19,19108:12

morale 100:10,11101:21 102:1

Morbidity 25:2156:3

morning 10:944:10 90:7,1693:1

Mortality 25:2156:2

Morucki 35:20mother 134:1

148:1,5 175:6motion 163:12move 17:9,11 40:8

40:16 43:1 51:351:6 58:25 61:561:8,16 62:5



Page 15

63:7 75:22 76:976:15 78:24,2579:1,2,5,12,1579:17,23 80:6,980:10,12 81:981:15 82:13,2084:10,11 85:2285:25 86:15,1986:24,25 87:1,593:17,19,23101:9,10 104:21104:23,25105:11 123:13125:1,16 126:9126:12,21,23127:1,12,18128:12 139:6142:12 144:11144:16 156:2160:17 178:14

moved 37:13,2438:1,2,6,11,1340:20 41:14,2542:2,3 43:4,1043:14,16 61:862:2,3,9,18 63:863:12 80:1782:19 84:13103:11 104:8,15104:16 122:16122:20,23124:12 127:17143:17 144:8145:11 157:10158:24 164:13

movement 38:145:3 46:7,1447:14 128:11145:3 148:4177:15

movements145:19 146:10

moves 42:15,1642:22,25

moving 19:1837:6 47:11

85:17 87:1594:3 105:3122:10 123:1125:13 178:3

MPD 28:10Mullins 3:2multiple 26:14,21

28:1 64:15,25114:2 115:21157:2 160:11

multitude 105:5125:20 167:18168:9

M.D 3:5,11,18

NN 1:7 2:1,16 3:3

4:1,15,15 179:1179:1,19,19180:12,12,22,22

name 4:16,1635:20 37:17138:19 152:11152:12

names 35:11Nancy 1:2 4:18

90:12,12 103:20narrow 7:9nature 116:20near 22:16necessarily 65:5,6

89:11 123:23126:18

necessary 67:15need 8:20 17:5,18

21:4 26:1 29:1530:5 31:4,5,2131:25 44:1756:15 69:1071:10 73:288:11 110:20125:11 128:16137:21 156:8

needed 12:1131:25 32:1933:9 34:22 63:2

82:22 95:4101:10 104:19110:4 156:5

needs 37:17,2538:3,7,12,1939:18,24 40:440:15 42:5,9,2343:1,4,10,1348:5,15,21 49:150:9,23 61:6,1562:7,10,12 63:163:15 79:3,683:4 87:1693:20,23 112:17118:6,7,10,14,18118:20 119:5,15120:17,20 121:3121:12 122:19122:22 123:11124:12 125:2,17125:23 126:2,7128:8 158:15161:1 163:13178:3,14

Negrette 3:5never 40:11 55:20

72:2 87:1106:10 116:8132:9 136:17180:24 181:6

new 16:16 104:10news 103:19night 62:15 71:7

92:15 127:16128:6

Nina 3:20nods 5:5note 69:9 86:1

87:17,24,2588:2

noted 130:8notice 4:7 5:17

27:15 168:16,17168:20,23 169:1169:4,12,18,21170:5,16,20,24

171:4,11,15172:4,12,19173:2,4

noticed 153:17notices 169:7notified 28:14

51:5notifies 85:25notify 27:19 51:2November 108:15

108:21 115:13NP 59:1 62:1number 91:12

92:1 94:19113:22 146:5152:13 179:13

nurse 48:20 49:767:14 69:9,990:4 91:16 92:492:25 93:3,4106:16 123:11136:21 138:11152:13,16

nurses 106:24116:13,17,20117:4,14 148:10151:14

nursing 147:14,22148:3

Nyklewicz 27:1735:3,3 68:19108:1

N28 2:4

OO 4:15 179:1,19

180:12,22object 7:4 10:17

21:16 26:2028:16 30:132:10 38:2440:10,23 45:1748:8 50:10,2453:1 59:18 60:961:1,16 62:464:9,20 66:12

71:24 73:2581:1,10 88:2190:22 93:1496:9,21 97:19102:11 105:21109:4,17 112:21112:23 119:4,23122:6 123:14125:3 133:8134:16 135:17136:25 137:11144:20 147:3148:20 165:23170:7 172:6173:5 174:15

objected 177:21objecting 119:10objection 10:23

39:14 42:1046:18 49:4,1349:16 50:1,1751:21 52:7,1560:16 67:7,17143:25 157:23158:7 159:3180:15 181:3,9181:23

objections 29:152:10 72:10,15106:3 148:22157:22 159:18160:3,11 161:4161:11,17164:20 182:6

objective 179:23180:4

Objectives 108:10obligation 29:21

109:12obligations 29:4

97:5 102:10109:13,25112:16

observations181:7

observing 65:16



Page 16

147:10obtain 68:14 71:2

140:11 141:9obvious 152:22obviously 22:12

165:9occasions 11:14

20:17 26:12,1495:10 96:13

occur 11:21 14:1743:5,6 63:586:19 122:5

occurred 14:718:12 23:1427:9 36:20 37:757:10 60:1 63:865:19 80:787:15 90:3 94:3113:6,22 114:9116:5 127:19131:1 135:16142:3 143:8

occurrence146:21,24,25147:2,8 149:10151:1

occurs 62:13offered 15:9 19:5office 2:3 10:13

15:8 16:17,1916:24 28:455:14 56:1088:25 98:16,22100:17 103:2163:8

officer 13:2219:17 34:2347:1 51:7,1053:5 58:2585:16,24 135:18136:6 137:6,17148:17 149:20150:4,19 151:12153:17 170:17181:20

officers 31:24

32:7 45:5127:20 174:1180:25

oftentimes 43:1462:13

oh 38:13 88:191:24 94:25137:23 139:21152:3 153:4166:25

okay 4:24 5:6,119:10,19 10:1411:5 14:5 15:1817:20 18:5,2320:1 22:8 29:2033:4 41:19 43:244:24 45:246:23 48:1259:11 68:2 73:476:7 77:2,2378:23 79:984:23 89:2591:14,24 98:17104:2,10 120:4127:23 128:15132:13 139:9,22142:22 143:1145:5 146:23152:10,20 153:4153:9 155:11161:24 162:2163:24 165:11165:18 168:22169:3 176:19178:20 179:11179:12,15,16180:18 182:11

once 9:9 28:1443:8 47:24148:16 160:2

ones 36:5 84:2170:19

onsite 86:19oop 165:3,3operate 32:2operation 32:20

33:10,12operations 14:21

14:22 16:1031:20

opinion 30:338:23 114:7117:21 151:2,3151:6

opinions 132:2opportunity 76:7opposed 126:8optimal 117:10option 63:4order 28:10 35:6

48:1,10,14,2549:5,10,11,20,2250:8 51:17 52:161:11,14 62:2067:1 68:21 70:770:15 118:20177:14

ordered 28:840:20 70:3

orders 40:1645:12,14 46:9,946:16 47:6,8,1047:17 67:15

organization 28:6original 4:13originally 7:23,24Otjen 3:8outcome 65:25

66:1 150:22outline 83:9outset 113:14Outside 182:1overall 106:10,17

108:10,14179:23 180:4

overflow 40:443:15,17,20118:7,8,10,14,18119:2,5,15120:9,13,17,24121:2,12 122:20124:13 125:17

178:4,15overly 28:17

105:22 119:7,11121:4 170:7174:15

overrule 61:1362:20,24

oversee 14:21overseeing 14:23oversight 95:18overtime 101:18

102:2overview 13:1

PP 2:1,1,20page 4:2,6,10

75:22 78:2084:8 89:22 92:392:3 108:9111:13 114:14129:13 130:3142:12 156:3,6168:20 171:2,19179:11,12,13

pages 129:6paid 114:20

115:15paper 18:3,15

46:25 55:6paperwork 15:5

16:23 46:2447:15 48:2,7,1648:22 49:3,2350:7,14,18,2051:2,16,1953:15 67:2,3,1599:23

paragraph 57:23114:15 130:4139:13 140:9145:17 146:4147:4 155:21

paragraphs145:15

parallel 28:22

part 12:24 14:1036:24 44:9 46:546:24 50:573:16 77:4 78:485:13 93:12113:19 116:2128:24 129:1130:14 131:22138:10 147:1155:16 166:12172:17

particular 7:1614:13,21 25:2145:14 48:1762:25 65:1969:16,24 70:1771:2 88:24126:11 135:21136:13 157:8164:11 173:17175:3

part-time 115:3pass 89:22 90:15

90:19,24 91:493:6 129:15152:15,16

passed 32:1764:13 88:6

patently 161:6patient 40:15

61:15 73:1484:13 85:1887:15 88:2494:3 130:7139:7 140:10,21140:22 141:8,21142:13,24 145:8147:17,21148:16 151:19153:3,12

patients 74:1885:4 156:7

patient's 147:10pay 101:16payments 106:11pending 151:7,9



Page 17

people 23:22 28:632:3 43:1453:20 60:1869:24 71:1374:9 93:6 110:5118:21 119:1,17120:2 124:16166:11 175:23177:8,25

percent 106:11108:14 111:20111:21 112:3114:16 115:4,14116:12

perform 112:15performance

155:8period 13:23

65:23 70:13,1998:6 101:5106:9 108:15109:21 112:20114:17 115:12118:2 159:23177:25

periods 78:25permanent 16:7,8

16:15 18:13,23person 10:5,7,8

24:8 39:1847:12 55:2,3,5,869:8 71:8 83:1584:2 86:15100:22 126:22139:15,18158:14 166:5

personal 6:4,9,237:14 8:8,1411:25 12:4,820:14,24 21:1021:13,14 23:824:2,21 41:855:15 76:17,1876:19 77:2,1177:21 78:6,8,9

personally 5:16

pertinent 64:6,1265:1 105:22111:4

petty 161:3Pewaukee 2:5phone 10:4,7,12

10:15 11:1517:21 51:2,6,8160:22 161:19

physical 46:2599:19 152:22,24153:1 156:8

physically 10:1145:6 49:6

Ph.D 3:17pile 179:3place 64:2,24 86:2

120:6 146:8170:3 175:8,14

placenta 148:7places 64:25Plaintiffs 2:6,12plaintiff's 164:1Plan 3:24 139:7

139:11 143:5145:14

please 4:16,23 5:813:2 23:2 30:1531:5 41:8,1659:9 113:16120:6 131:4134:17 152:2155:8 174:17

plenty 91:22plethora 124:14plus 58:25pod 64:16,18,24

65:7,12 66:1067:5 129:21142:25 145:9

point 9:17,1811:11 17:8 20:824:8 41:2345:15 47:1853:7 56:6 57:1884:5 108:11

117:13 153:17pointing 51:6policies 26:8

117:25 118:4120:2,6 173:12173:15 174:2176:16

policy 43:19 47:247:2 64:2 86:1,4118:13,16,25119:18 120:9,12120:14,24 121:1123:6 134:3,7134:10,19 138:7170:3 173:1,23174:3,5,19175:1,3,4,7,13175:19 176:2,5176:9,10 177:2

pool 114:20 115:3115:15 116:4,13116:17,20 117:4117:14

Porlucas 3:18portion 108:20

170:15posed 164:6position 15:2,6,7

15:9,12,14 16:616:8,14 17:1718:1,2,9,13,1518:22,23 19:521:5 30:1153:17 56:2196:3 115:16,24139:1 159:22161:3 164:7

positions 98:21106:16 114:18116:4,5

possible 68:1671:4 73:16

possibly 17:10post 31:10 50:5

129:2 154:18power 100:4

precludes 29:1prefer 164:17pregnancies

126:4pregnancy 39:18

39:25 42:4,863:19 64:8,1167:4

pregnant 40:564:4,17 65:3,965:17 66:1083:3 118:19125:24 141:21155:2 157:8158:23 164:12174:8

prenatal 93:8129:24 130:7

prenatals 88:18preparation

10:10,19 44:2059:15 91:6144:13

prepared 105:13158:13

prescribed 93:9present 9:21

85:17 127:21162:16

presented 147:21preservation

29:24preserve 28:14

29:5,24 30:17preserved 29:16pretending 71:25prevent 143:18

144:9prevented 123:12

128:4preventing 113:5

123:1previous 162:21previously 5:14

7:17 44:3 56:857:21 58:17

67:2 76:14117:24 136:20171:17 173:10178:10

primarily 81:1482:8

prior 9:5,6 10:1210:15 11:15,2116:14 21:1723:24 28:2147:11 52:2154:20 57:258:20,21 60:760:14 61:5,863:19 75:4 94:994:10,12 98:1598:22 101:24104:8 113:20116:3 136:19137:9 159:9163:6

privilege 10:18165:4

privy 65:24 66:191:1 114:3136:17,19150:22

proactively 19:6probab 71:7probably 17:23

20:20 68:19problem 22:7

31:22 38:2339:23 46:2472:13 76:880:19,24 81:882:18 89:16126:20 132:19136:7 140:10141:3,8,13,20,24142:7,13 143:4143:7,7,8,11,21143:24 144:18145:1,7,16163:11,13

problems 31:21



Page 18

31:23 32:18101:21

procedure 32:943:19 56:2557:1 58:9 60:364:2 86:2 99:19118:13,25119:19 120:9,12120:14,24 121:1134:3,7,10,19138:7 161:6,10170:3 173:2,23175:7,13 176:2177:2

procedures 26:8118:1,5 120:3173:12,15 174:2

proceed 26:19161:5 162:7,9163:10

proceeded 13:23proceeding

161:12process 15:4

16:21 17:1519:1 20:1227:15 32:9 46:146:6 47:1753:15 95:15116:6 121:16131:15,22132:14 138:25145:2 146:8

processing 99:24produce 5:22 6:3

7:2,3,12 24:377:5 78:5

produced 4:8 5:216:4,12,15 44:944:12 75:2376:22 77:7,1077:15,19,21,2488:10

produces 53:20production 5:19

5:22 44:10

professional76:18,23 77:12

professionally21:2

progress 168:11promoted 14:9

16:1,19 53:4,653:20

promotion 14:1,514:15 15:4,2316:14,21 17:1052:24 53:1254:12,20 101:6

promotions 54:955:7

prompted 36:1236:22 84:18

prompts 48:16proper 46:16 47:2

56:25 57:1 58:960:3 134:2137:9 166:10

properly 32:2333:16 52:12,1352:20 60:24110:2 112:5,19114:4 136:3171:25 173:4

protect 21:5Protective 171:22

172:18proved 31:8provide 18:8 68:8

68:16,25 71:473:19,20 90:14116:18 117:5129:3

provided 48:2571:10,18,1973:23 74:3,1174:17,20 75:1,875:13,15,1978:11 90:692:25 97:14112:15 117:16129:24 138:10

146:24 147:1158:17,22159:20 160:10161:14 171:11173:13 179:21

provider 141:22providers 156:7

157:3,12,20providing 76:12

78:14provision 110:10

115:17PSW 86:19Psych 139:17psychiatric

106:17,25published 103:23purpose 8:14 12:7

32:15 45:2168:9 169:3171:24 173:19174:20 175:1

purposes 95:14pursuant 5:18

67:24 68:4112:24 118:4

pursue 164:2put 45:15 46:11

51:13 58:659:17 62:1664:12 87:889:24 92:1095:21 121:20146:8 160:14

putting 51:858:20 60:7,1483:2

P.C 3:14p.m 75:23 78:15

78:19 85:1686:19,22 87:12127:19 182:13

Qqualities 54:5,22quality 117:17

question 4:23 5:15:8 7:6,9 10:2210:25 11:321:17 22:528:17,25 30:930:14 32:9,1139:5 40:13,2441:19,21,2249:18 56:1759:6,12 65:2368:2 70:2071:12,25 72:972:17 74:3,2075:18 77:1880:4 81:2,11,2482:3,7 83:16,1889:23 90:2,8,1792:15 103:13109:18,19 111:7111:11 112:24113:15,19 114:5116:25 117:9,13119:6,11,21,24120:7,22 122:7123:22 124:7125:3,7 127:7,9127:13 128:7130:18 131:3133:9 134:17137:10 141:11143:9 148:21,25149:3,13,18,19149:23 151:8,9155:19 156:15156:15 158:8,12159:23,24 160:4160:16 163:3,6163:21 164:4,6165:6,10 174:17174:23 175:2177:20 180:9182:5

questioning162:10

questions 4:1920:10 21:20

23:4 34:22 41:784:13 129:9161:23 176:22180:3 181:15182:9,12

quick 176:20quoted 147:17

RR 2:1raise 102:16

109:25 112:3raised 111:14rank 101:9ranks 13:24Rd 2:10reached 30:7read 57:18,25

76:5 131:11136:12 140:23141:1,2,5142:20,21 145:4145:20,21149:15 155:21156:20 162:16

reading 67:2584:16 86:14147:5

ready 105:17reality 18:5 19:12realize 19:12really 35:14reask 120:6reason 12:13 37:8

70:17 77:478:13 83:1485:18 86:16,2087:18 95:16106:12,18108:16 114:21115:8 126:11140:12,18141:23 142:15143:3,23 145:6146:25 147:11147:15,18,23



Page 19

148:1,5,7,11,14148:19 149:3153:13,17 154:3158:8

reasonable181:20

reasons 17:3,720:11

recall 8:9 9:411:17,19 12:1320:18,22,2325:22 34:8,1635:14 36:6,7,1036:18,20,2537:2 42:20 53:253:10 54:11,1355:9 63:21 68:873:18,22 74:1978:16 80:182:17 83:13,1984:1,7,19,19,2284:24 85:5,7,1185:23 86:5 87:387:7,11 88:7,1689:18 94:5,7,1494:18 95:1196:14,16 97:997:22 98:18,20100:20 101:4,13101:15 102:12102:18 103:6,11106:4 108:7114:11,13 121:5125:25 126:5,10127:16 128:9,14130:20 132:16138:14,21145:13 177:11

receive 90:9,10170:19 177:8

received 9:1117:4,21 51:1354:19 66:2372:2 78:12 83:583:7,7 88:1890:11 140:13

143:12 146:13162:6 177:18178:17 179:22179:23

recite 124:15recognize 171:18

178:13recollection 55:25

170:8recommendation

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53:21recommending

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6:14 7:19 8:611:5,6,7,8,1012:11 41:9,1354:22 59:4 73:573:6,7,15 75:975:10 86:8 88:988:14 89:13100:9 123:20128:19,20,21142:10 152:4159:13,14,15,16160:25 161:21162:3,4,5,11,15162:20,23 163:4163:10 165:16165:16 166:17176:23,24,25178:22,23,24182:13

recorded 180:25records 12:10

21:3,6 37:1269:7,13 74:1885:15 90:5,899:13,15,21124:15,18,21135:22,23144:12,13165:20,21 166:3166:8 178:18

refer 175:21reference 69:15

99:22referencing 57:13referred 87:15

94:3referring 6:18

8:25 24:5 31:147:15 59:2 66:379:19 91:9 92:193:11 94:16107:25 135:23136:5 139:20140:4 152:23

reflected 12:17110:22 143:4149:9 150:25153:20

reflects 75:9,11refusal 140:11

141:9refuse 156:8,11

156:17refused 140:10,21

140:22 141:8,21147:21 156:21

refusing 10:2211:2 156:14157:2,11 158:22164:15 175:6,12175:24

regard 29:2533:20,25 37:1066:18 73:1782:16 114:22117:21 119:18124:20 130:19134:10 146:4176:3 177:18

regarding 4:205:25 24:1 25:825:24 34:2 42:549:21 51:1855:7 61:1467:15 75:2594:15 95:18

100:1 161:16176:7 178:13

regardless 120:20121:8,24

regards 84:13registered 106:16

106:24regular 84:22

117:6,17regularly 107:7

107:23reiterate 145:18

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101:23relates 9:8 12:22

22:2 24:24 27:829:5,22 30:1831:16 33:2434:4,18 35:7,1236:8 40:9 42:2244:20 46:6,1347:6,16 50:8,1552:13 67:4 69:169:21 70:1274:9 84:24 85:988:14 96:2102:10 106:24110:22 112:6118:14,18,21119:1 120:13,17120:25 121:2122:10 132:4133:25 138:18140:13 141:13141:24 142:7,16143:11 144:18166:3,8 167:2,6167:9,12,18175:1,4 176:10

relation 9:3 12:1233:18 66:1568:11 111:19114:8 139:10

relative 39:24108:4

relayed 36:21releasing 99:23reliance 108:13relieved 105:13rely 7:3 159:9remain 13:17

15:10 17:12,1648:5,15,21 49:150:8,23 53:8115:3,24 118:20123:11 159:2164:18

remained 111:20remember 14:3

15:24 18:1835:23 55:25103:18 124:22165:12 169:2

remembering35:18

reminder 119:10removed 70:7

148:16repeat 32:12 39:5

41:19 49:1859:12 109:19111:11 116:25134:17 138:19174:17

repetitions 164:4rephrase 4:24

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27:12 95:20,2296:4 99:25106:7,8 110:22114:14 128:25129:5,11 131:19131:21 146:21147:2 149:10151:1 153:16155:16,25156:22 171:22171:24 172:18

reported 24:14,1638:17 45:24



Page 20

60:13 85:17100:3 148:3,13148:17 149:16153:12

reporter 5:5 11:611:8 73:5,791:17 92:5,7119:8 128:19,21152:1 153:6,9159:14,16161:22 162:3,5165:11 176:23176:25 178:21178:24 179:16180:10,20182:11

reporting 131:22155:15

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required 35:849:2

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requirements171:7

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restrictions 47:14125:19

result 26:10138:23 139:3

resulted 38:946:15

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reviewed 4:957:21 108:12

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93:2,23 101:25106:6 107:20114:5,14 115:8116:2,6,13119:8,17 120:10121:15 123:24124:9 126:23127:6,21 128:1131:7 134:21136:24 137:25140:9 147:6149:13 151:16151:19 152:20153:11,21 154:1155:7,21 156:2158:20 159:12162:3 164:2166:6 168:23170:6 171:10172:4,12,19,22175:12,21178:21 180:5,9

risk 45:11 145:3145:11,20146:10

role 12:24 30:2030:21 31:2056:8 70:24 89:195:7 104:16105:5,18 107:16107:18,20131:16

roles 81:3Ronquillo-Hort...

3:11room 62:12 63:16

91:20 162:8,13162:20,25 163:2163:8 165:5

root 142:12 145:1145:4,6,16

rounds 33:1,3,1964:4 65:15136:6 137:6151:19 153:2

Roundy 2:4

row 156:22 157:3rules 161:5,10run 31:20Russart 2:20 4:4

46:20 61:185:10 86:388:21 93:1496:9,21 97:6,1997:25 98:8102:11 103:3106:21 107:2,4107:12,22 108:6108:18 109:5,16110:3,13,15111:3,7,16,22112:7,22 113:8114:1,24 115:5115:9,20 116:7116:14,21 117:8117:18 128:16129:8 138:13140:14,20141:17 142:1,9143:6 144:4,22155:17 157:14157:22 159:5,7160:18 162:14165:1,3,13,15,23178:25 179:2,15180:1,9,10,11,13180:18

Russart's 180:2

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Page 21

84:9 122:14139:25 143:15150:15 163:16

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scanned 4:12scene 133:23

147:14scheduled 122:14

152:21Schmid 2:25Schmidt 5:25 6:9

6:25 16:2517:14,22 18:719:2,9,11 20:2,424:6,11,14,1625:14,18,2326:3,7,13,2527:2,8,12,14,1927:22,23 28:836:7,15 53:2254:8,23 55:7100:3,4,14,16101:23 102:7,14102:16 104:13104:13 105:1,3105:10 131:21131:24

school 13:12scope 158:2 182:1

Screening 173:18173:19

sealed 4:13search 99:13,15

99:18,18,19,19100:9

second 9:19 10:636:2,20 78:2098:14 139:24156:3

secretary 49:6secure 68:17

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see 44:7,9,2457:25 69:15,2574:18 75:2576:16 77:2 78:778:18 80:187:16 91:3,6115:6 118:7120:9 122:14123:8 127:23130:5 132:13133:4,16 136:22137:7,17 139:20143:17 144:11

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seen 44:4,11130:2 135:22138:12 141:21175:10 180:24181:6,11

send 7:24 47:2,355:2

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sensitivity 29:8sent 4:13 8:20

19:16 20:266:23 75:2477:12 78:593:13 146:12156:8,12

sentence 73:1187:12,19 147:7153:11 155:12155:12

sentences 87:19separate 26:23separated 147:25separately 26:18sequence 36:18

37:6sergeant 14:2,5series 4:19 26:7

168:14 173:12served 5:16 10:1service 122:4services 2:24 4:11

69:22 74:8 80:6103:2 121:23,24173:18

set 6:15 7:1666:20 149:14

sets 6:15seven 112:18Shade 12:12

29:16,18,2230:4,18 31:632:16 52:1468:15 71:3139:7

Shansky 95:4,6Shansky's 96:2shared 66:17,19sheet 65:7,12

66:10 67:5sheets 64:16,19,24sheriff 5:24 6:24

6:25 20:5 54:2378:6 99:3 100:1100:7,14,17102:7 104:13,17105:1,1 173:11

sheriff's 6:2 8:128:22 10:13,1512:5 16:17,1919:3 21:5 23:1925:5,15,19 28:355:14 56:1098:16,22 103:25104:4 124:16

shift 14:21 16:1016:11,12 17:617:12,16,1936:1,2,2,3

shifts 17:9,11short 17:4shortly 102:22shoulders 5:6show 5:14 28:9

44:3 71:6 77:2089:20 102:25117:24 165:18166:15 168:13171:17 173:10

showed 44:6 72:4101:23

shows 71:13 92:18shrugs 5:6sick 152:14side 51:20 82:12

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sit 26:6,17 59:1686:16 95:1598:4 108:24141:12 150:23151:10 154:21155:14,23169:16

site 139:15,16,18139:18,21,25140:1,4

sitting 91:23situation 62:14

125:6 135:6,7135:18 154:15154:17 178:10

six 139:14 164:3179:14

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142:20 147:5smooth 56:9SMT 142:25

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Page 22

software 92:10solely 76:22solution 146:11solutions 117:16somebody 19:9

20:3 24:1049:25 53:1758:18 60:6 79:681:8 82:5,1992:9 107:21125:16 131:20150:11 157:19167:17

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sort 66:23 125:19sought 19:6space 43:15 62:15

63:4,6,17 124:3163:8

speak 8:5 10:1431:6 34:10,2136:25 119:9124:18 152:16178:18

speaker 160:22161:19

speaking 29:334:17

special 37:15,1737:24,25 38:3,738:12,19 39:1839:24 40:4,1542:4,9,23 43:1,443:10,13 47:6,8

47:10,17 48:548:15,21 49:149:20 50:8,9,2351:17 61:6,1561:25 62:7,1062:10,12,2063:1 67:1,1579:3,6 83:387:16 93:20,23118:6,7,10,14,17118:20 119:5,15120:17,20 121:3121:12 122:19122:22 123:11124:12 125:2,17125:23 126:2,7128:8 178:3,14

specialties 81:5specific 28:3 30:3

36:1 62:5 65:1467:23 69:1171:1 114:17124:23

specifically 18:221:25 36:1038:20 61:21129:10 136:4,9156:16 176:16

specify 130:1143:7 161:1

speculation 64:2167:8,9,18 90:2397:8 122:7140:6 143:16144:21 154:5,12180:16 182:1

spell 4:16 35:20spoke 10:12 11:14

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staffed 111:20staffers 103:22staffing 96:11,20

96:23 97:4,1297:14,15 98:7102:3,4,9,16,20106:10,15,17,23106:25 107:7,21107:23 108:2,4108:12,13,14109:2 110:4,4111:15 112:13114:16,19,19115:1,4 116:5,8116:15 117:10117:16

stamp 152:18172:21

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started 79:21starts 76:10state 4:16 72:17

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stats 24:3Status 118:5,6

171:22 172:18stay 98:12 129:13

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Page 23

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surrounded 32:6Swayzer 1:10

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118:19terminate 29:12

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22:6 23:9 24:2226:8 28:18,2229:3 113:12,18113:23 114:9

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time 9:17,18



Page 24

11:11 12:1413:8,23 14:3,414:12 15:6,9,1215:17 16:1817:4,8 18:1320:9,9 23:2124:8 27:1235:24 36:6 37:139:7 41:2347:18,19 53:954:18 55:856:19 60:1863:8 65:2368:14 69:8,9,1069:17 70:1,1270:19 71:2,672:5 73:1181:23 84:5 86:286:20 89:190:12,24 93:7,998:2,5,14,1899:13 102:20109:21 112:20114:16,20 115:3115:15 118:2119:9 123:2129:25 133:1,6133:18 137:10139:1,4 143:22146:12 147:7152:18,18 154:4154:10 155:5159:23 162:23167:1,25 168:4168:6,7 177:25178:19

timeline 78:11timeliness 181:15timely 130:16,22

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