A Maine Department of Corrections review found that Cumberland County Jail staff members were following “expected practices” when they used pepper spray to subdue two inmates before transporting them to a state psychiatric facility.

But an advocate who requested the investigation said the reports show not enough was done to deescalate the situations or make other accommodations for the inmates experiencing psychotic episodes.

“It is time for an independent review, at least . . . from the perspective of how they are responding to mental illness,” said Jenna Mehnert, chief executive officer of the National Alliance on Mental Illness Maine.

Cumberland County Sheriff Kevin Joyce said he was pleased that the reviews reaffirmed that staff followed proper procedure but added, “There is always something to be learned from every incident.”

The incidents date back to early 2019 and involved two inmates at the facility. In both cases, the male and female inmates were slated to be transferred to the state-run Riverview Psychiatric Center in Augusta for evaluation or treatment.

During the February incident, jail staff “spent several minutes communicating with (the inmate) through his door vent . . . in an attempt to influence into voluntary compliance to submit to search, restraints and transport.”

Videotapes reviewed by the Maine Department of Corrections manager of correctional operations, Ryan Andersen, say that jail staff told the inmate that he had an appointment for an evaluation and that “we’re going to get you some help, that’s why we’re going to the hospital to take you to a doctor today.”

After these efforts failed, an officer sprayed pepper spray through the food chute in the cell door. The inmate then placed his hands through the door to be cuffed and was escorted to another area to flush the pepper spray with “a steady flow of water in an open area.” The man was also reportedly uncooperative when the jail’s health care staff tried to help him wipe his face.

But when the inmate arrived at Riverview, hospital staff determined that the spray had not been properly washed off before the hour-long drive from the jail, and that the inmate “displayed a concerning physical reaction consistent with having been pepper sprayed.”

“Riverview staff immediately provided appropriate care, including showering the patient to remove remaining spray and a referral to a hospital based on the patient’s severe symptoms,” Jackie Farwell, spokeswoman for the Maine Department of Health and Human Services, said in a statement when asked about the incident last month. “(Riverview) Superintendent Rodney Bouffard promptly contacted Sheriff Kevin Joyce after the patient was admitted to express his concerns about the patient’s condition, including that the patient did not appear to have been appropriately cared for by jail staff following the apparent use of pepper spray.”

In his report, Andersen wrote that after reviewing the materials and interviewing jail staff, “the information obtained was measured against Mandatory Standards and I have determined CCJ staff acted in compliance with expected practices.”

Andersen reached an identical conclusion regarding another pepper spraying of a Cumberland County Jail inmate being transferred to Riverview a month later. In that incident, both jail officers and health care workers attempted to convince the woman to voluntarily stick her hands through the door’s food chute for handcuffing.

But in this case, it took two bursts of pepper spray — separated by more than four minutes — before the woman complied with the officers’ requests.

“Immediately following the second burst of OC Spray, (the inmate) submitted to the application of mechanical wrist restraints by placing her hands through the food chute,” Andersen wrote. She then walked to another area where the pepper spray was flushed and she was examined by healthcare staff before being transported to Riverview, he wrote.

Mehnert, the NAMI Maine advocate, said she first raised concerns about the February 2019 incident later that year and tried to handle the issue privately with Joyce. But after having no success, she spoke with the media last month. Andersen’s review was completed less than two weeks later.

Mehnert said the federal Americans with Disabilities Act applies to people with mental illness and requires agencies to make “accommodations.” But she said in Andersen’s reports “there is not a single mention of the ADA and what accommodations were made in these situations.”

“They are in a psychotic state,” Mehnert said. “The ADA absolutely applies to the actions of law enforcement and corrections. The ADA doesn’t say, ‘You have to do this and this’ but it says you have to think of things differently . . . and does require the Department of Corrections and law enforcement to take into consideration a person has mental illness.”

NAMI Maine has a contract with the state to implement what’s known as a “Crisis Intervention Team,” or CIT, program that trains law enforcement officers on how to more effectively handle situations involving individuals in mental crisis.

CIT programs also connect law enforcement with mental health professionals, community support groups and advocates so that police can play a more supportive role in getting people help rather than sending them into the criminal justice system. More than 50 police agencies in Maine, including seven of Maine’s 16 county sheriff’s offices, participate in CIT programs but the Cumberland County Sheriff’s Office is not among them.

Joyce said his goal is to have every officer in the sheriff’s office to have some mental health training but “that is a tough hill to climb” with such a large agency. The Cumberland County Jail has four mental health case workers as well as a mental health nurse practitioner but, with between 300 and 400 inmates on any given day, they are “just skimming on top of the waves.”

But both Joyce and Mehnert agree that the bigger, underlying issue is that a lack of services and resources to help people with mental illness mean that many end up in jails that have become defacto psychiatric facilities.

“At 2 o’clock on a Sunday morning, no one is open so you call the jail,” Joyce said.

Riverview has had its own high-profile incidents involving pepper spray and physical restraints being used on patients.

In 2013, the 92-bed facility was decertified by the federal government because of a number of serious deficiencies, including the use of pepper spray, stun guns, improper restraints and seclusion of patients.

In one case that triggered a lawsuit, a woman housed at Riverview after being deemed not criminally responsible on arson and assault charges was reportedly pepper sprayed by correctional officers working at Riverview. The woman was then restrained and was not allowed to shower to remove the spray for three hours.

Riverview regained its federal certification last year after making significant improvements to patient care, filling numerous staff positions and operating under court-ordered monitoring.