An internal affairs investigation into the death of an inmate at the state’s largest prison reached “false and self-serving conclusions” as part of an alleged cover-up of flaws in the training and actions of prison staff members, according to a report by an expert in correctional mental health systems.

The report by Dr. Pablo Stewart on the suicide of a Halawa Correctional Facility inmate five years ago alleges the investigation by Internal Affairs investigator Darren Tsuha contradicted the “clear video evidence” in the case that showed a corrections officer failed to make required cell checks on the inmate.

“In fact, it is my opinion that the Internal Affairs Report prepared by Tsuha, and approved and accepted by Warden (Scott) Harrington, was an attempt to cover up serious staff errors and omissions that any competent investigator would have identified,” Stewart wrote.

Stewart’s scathing report on the death of prisoner Joseph O’Malley was filed in Honolulu Circuit Court in January in connection with a lawsuit in the case, and the state Attorney General’s Office admitted the state was liable for O’Malley’s death. Circuit Judge John Tonaki awarded O’Malley’s estate $1.375 million in the case in March.

Stewart is an acknowledged expert on adult and juvenile prison mental health systems who has reviewed facilities in California, Arizona, New Mexico and Illinois, and his report details an array of alarming flaws in the Hawaii system linked to the handling of O’Malley’s case.

The Department of Public Safety declined on Wednesday to answer more than a dozen specific questions about Stewart’s report, but said in a written statement that it “has sound policy for the care and custody of inmates with mental illness.”

“The department routinely reviews and updates all policies, and the training on such policies, including the inmate suicide prevention policy which is in accord with national standards. Issues identified in the court proceedings and final judgement either were resolved or are currently being addressed,” according to the statement.

“The department has no further comment to make,” it said.

The Hawaii Correctional Systems Oversight Commission will take up the O’Malley case during its regular meeting at 9 a.m. Thursday.

O’Malley was moved from suicide watch to “safety watch” on July 11, 2017, and finally used a strip of clothing to hang himself in an observation room in the medical unit of Halawa Correctional Facility on July 27, 2017. More than 25 minutes elapsed between the last check of O’Malley in his cell, and the time he was found after hanging himself.

Stewart wrote that “perhaps the most alarming” aspect of Tsuha’s internal investigation into O’Malley’s death was Tsuha reported a corrections officer had made the required checks of O’Malley in his cell every 15 minutes despite a video recording of the hallway outside the cell that showed the officer walked by the cell without looking inside.

In fact, O’Malley had used paper to cover the window of his cell before he killed himself, and the video showed the corrections officer walked down the corridor “without even turning his head in the direction of the blocked window into the cell,” according to Stewart’s report.

That corrections officer said in his deposition in the case that he “did not even understand that he was required to monitor inmates on Safety Watch,” according to the report.

The internal affairs investigation also falsely asserted corrections officers and the nursing staff at Halawa had been properly trained in the suicide prevention policy when they had not, Stewart wrote. One corrections officer reported in his deposition he did not recall undergoing any required suicide prevention refresher classes during his six years at Halawa.

“These false and self-serving conclusions are disturbing because they demonstrate that not only are the suicide prevention practices at HCF woefully inadequate, but (Halawa) and DPS fail to exercise any type of oversight, and in fact exhibit an active unwillingness or inability to enforce DPS’s own policies,” Stewart said in his report.

Stewart’s report also notes Public Safety’s then-staff psychiatrist Louise Lettich said she did not even know the department’s suicide prevention policy existed until she was preparing for her deposition for the O’Malley lawsuit.

Lettich also said in her deposition she was unaware prison staff were confining inmates on suicide watch and “safety watch” in their one-man cells for 22 or 23 hours per day.

That practice of isolating suicidal inmates was another problem, because depriving those inmates of human contact including visits, calls to family and recreation time can dramatically aggravate mental illnesses, and may even be “profoundly damaging” to the mental health of inmates with no history of mental illness, Stewart wrote.

Yet Stewart’s report quotes the depositions of corrections officers who reported inmates on suicide watch were held in their single cells for 24 hours per day except for showers, and prisoners on safety watch were generally in their cells for 23 hours per day. The safety watch inmates were not allowed out-of-cell recreation unless “the doctor gave them a rec memo.”

Stewart concluded suicidal inmates were being held in isolation in violation of American Psychiatric Association standards and the department’s suicide prevention policy, “apparently without the knowledge of their treating medical providers.”

Prison policy at Halawa clearly calls for the transfer of inmates to Hawaii State Hospital for treatment if they are so severely mentally ill that they cannot be properly cared for at Halawa, but Harrington said in his deposition that he could only recall one instance when an inmate “possibly” was transferred to HSH for that reason.

Lettich said in her deposition she was unaware such transfers were even a possibility, but opined that O’Malley would have benefited from a more therapeutic environment than Halawa could provide, Stewart wrote.

Another alarming finding by Stewart was that O’Malley and possibly other inmates were punished for acts of self-harm.

O’Malley was informed the day before he committed suicide he would be placed in solitary confinement after his discharge from safety watch, a punishment Stewart said was apparently because a prison “Adjustment Committee” found O’Malley guilty of “self-mutilation” on July 20, 2017 when he had cut his own wrist with a disassembled fingernail clipper.

Harrington said the policy at Halawa was that inmates should not be sanctioned for injuring themselves, but the disposition in O’Malley’s case was “60 days lockdown,” according to the Stewart’s report.

The Department of Public Safety said in its statement to Civil Beat that Harrington, who was the warden at Halawa when O’Malley died, retired in late 2021. Tsuha, the internal affairs investigator who handled investigation into O’Malley’s death, retired at the end of 2020.