The hostage taking and death of a Delaware corrections officer on Feb. 1 was the result of poor management on many levels at the James T. Vaughn Correctional Center according to an independent review of security conditions at the prison, released Sept. 1.

The study was ordered by Gov. John Carney following the Feb. 1/2 incident, which resulted in the death of Sgt. (later Lt.) Stephen Floyd. Two other officers were injured and another staff member was sent to the hospital as a precaution after state police and corrections officers breached what is known as Building C within the prison, ending the standoff.

Carney ordered the review team to examine conditions inside the prison that contributed to the hostage situation. It found that while the incident could have taken place anywhere inside the sprawling prison near Smyrna, conditions particular to Building C ultimately led to the uprising.

According to the executive summary, “For some period of time, conditions at the JTVCC had deteriorated to the point that there was unrest among the inmates, and distrust between inmates and correctional officers, as well as between correctional officers and JTVCC administrators.”

Many officers felt unappreciated by their superiors, felt rules and regulations were inconsistently applied, considered an inmate grievance system unfair and distrusted the prisons’ medical and mental health system.

Handwritten testimony from some prisoners detailed mental, verbal and physical abuse by some officers, including spraying them with Mace or Capstun while in their cells.

Another problem was the lack of morale among line officers, the report stated.

Additionally, mixing maximum-security with medium-security prisoners “hastened the inevitable,” according to the executive summary.

Ironically, the report noted, less than two weeks before his death, Floyd had asked some of those prisoners be removed from Building C.

Had that request been carried out, “the incident and the resulting death may not have occurred,” the report said.

One inmate wrote the entire situation could have been avoided had the warden and others “paid attention of the concerns and grievances of the inmates instead of ignoring them.”

Because the Department of Correction still is conducting an internal review, it is not known if steps were taken to honor Floyd’s request.

The report also did not lay blame on any particular individual for Floyd’s murder; that is to be determined by a still ongoing criminal investigation by the Delaware State Police.

Carney said the report brought many of the conditions at the prison to light and already have resulted in changes.

“This much is clear: we have systemic issues within our correctional system that must be addressed, and we are committed to addressing them,” he said in a statement released before a 9:30 a.m. press conference in his Wilmington office.

“In the coming days, we will review these final recommendations in more detail. And we will take appropriate action that will continue to improve safety and security for officers and inmates inside our facilities,” the governor continued, adding, “We owe that to Lieutenant Floyd and all of the victims of the events on February 1.”

The report notes that since the incident, a new chief of prisons and a new warden for the Vaughn Center have been appointed with and that a temporary appointment has been made to oversee the implementation of new security procedures. The state’s FY 2018 budget includes $16 million for DOC officer salary increases and $2.3 million to pay for new corrections officers. A new labor management committee also was created to examine a number of personnel issues.

There is more work to be done to correct all of the problems at the Vaughn Center, the report notes. However, if the problems are not fixed, “these issues will continue to provide a fertile ground for violent incidents in the JTVCC.”