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Audit of the Middlesex Sheriff’s Office - A Review of Healthcare and Inmate Deaths (December 19, 2025)

December 19, 2025 · Middlesex County Sheriff's Office · Read the full official report on mass.gov ↗

Published December 19, 2025 Audit covers July 1, 2021; employee settlement agreements extended – July 1, 2018 to June 30, 2023 Under Diana DiZoglio · 2023–present

In plain English
The audit found Middlesex Sheriff’s Office generally met the reviewed healthcare, inmate death, mental health, and settlement reporting rules, but it had two documentation problems: it could not show written approval for late inmate death reviews, and it lacked a written policy for employee settlement agreements.
source
“Below is a summary of our findings, the effects of those findings, and our recommendations, with hyperlinks to each page listed.”
Read the plain-English breakdown
What is this?

This is a Massachusetts State Auditor performance audit of the Middlesex Sheriff’s Office, focused on inmate deaths, healthcare oversight, mental health services, and employee settlement agreements.

“In accordance with Section 12 of Chapter 11 of the Massachusetts General Laws, the Office of the State Auditor has conducted a performance audit of certain activities of the Middlesex Sheriff’s Office (MSO) for the period July 1, 2021 through June 30, 2023.”
Why was it audited?

Auditors checked whether MSO followed state rules and its own processes for inmate deaths, healthcare meetings, mental health services, and employee settlements.

“The purpose of our audit was to determine the following:”
Why it matters

When someone dies in custody, the public needs confidence that required reviews are done on time or that delays are properly approved and documented.

“Without properly documenting extension approvals for clinical mortality reviews, MSO cannot substantiate that extensions were granted for these reviews.”
What's in it for me?

For ordinary residents, this audit is about whether a public law enforcement agency can prove it follows rules when people are in its custody and when it spends public money on employee settlements.

“In fiscal year 2023, MSO’s annual state appropriation was approximately $75,997,810.”
The bottom line

Auditors found MSO complied with several key requirements, but recommended stronger written documentation for death-review extensions and settlement agreement procedures.

“For this objective, we found that MSO complied with 103 CMR 932.17(2).”
What happens next

The Auditor’s office says it will check back in about six months to see whether MSO acted on the settlement policy recommendation.

“As part of our post-audit review process, we will follow up on this matter in approximately six months.”
Jargon, unpacked

A clinical mortality review is a review after an inmate death to see whether the medical care was appropriate and whether policies or practices should change.

“Section .05 of MSO’s “Policy and Procedure 617—Procedures in the Event of Death or Serious Illness of an Inmate” defines a clinical mortality review as, “An unbiased assessment based on all the facts and circumstances of the appropriateness of the clinical care to ascertain whether changes in policies, procedures, or practices are warranted, and to identify issues that require further study.”

2 figure(s) pending source verification - not shown

What the Auditor checked

What the Auditor found

MSO could not provide written evidence that extensions for clinical mortality reviews were approved.
recordkeeping/documentationinternal controlspublic safety

Why it matters: MSO cannot substantiate that extensions were granted or demonstrate compliance with its own policies when reviews exceed 30 days.

Standard: Section .09(7) of MSO’s “Policy and Procedure 617—Procedures in the Event of Death or Serious Illness of an Inmate” ( Section .09(7) of MSO’s “Policy and Procedure 617—Procedures in the Event of Death or Serious Illness of an Inmate” )

2 recommendations
  • MSO should document, in writing, and maintain extension approvals for, clinical mortality reviews.agency: disagreed
  • MSO should update Section .09(7) of its “Policy and Procedure 617—Procedures in the Event of Death or Serious Illness of an Inmate” to include written documentation requirements for extension approvals for clinical mortality reviews.agency: disagreed
Agency response & Auditor reply
Agency: "The MSO objects to the [Office of the State Auditor’s (OSA’S)] Finding 1 being categorized as a “finding.”"
Auditor: "Without requiring evidence of the special sheriff’s approval, MSO cannot prove that it is in compliance with its own policy when clinical mortality reviews are not completed within 30 days."
MSO lacked written policies and procedures for employee settlement agreements and supporting records.
internal controlsrecordkeeping/documentationprocurement/contracts

Why it matters: The absence of a written process increases the risk that employee settlements may be handled inconsistently, inefficiently, or without adequate controls over restrictive clauses.

Standard: 815 CMR 5.09; US Government Accountability Office’s Standards for Internal Control in the Federal Government ( 815 CMR 5.09; US Government Accountability Office’s Standards for Internal Control in the Federal Government )

1 recommendation
  • MSO should develop, document, and implement a written policy related to employee settlement agreements, including prohibiting the use of non-disclosure, non-disparagement, or similarly restrictive clauses in its agreements, as recommended in the Governor’s “Executive Department Settlement Policy,” issued January 27, 2025.agency: disagreed
Agency response & Auditor reply
Agency: "The MSO also objects to Finding 2 being categorized as a finding, as the MSO meets the relevant criteria for employee settlement agreements."

More audits of this entity

Other Office of the State Auditor reports on Middlesex County Sheriff's Office .

See this entity's page with all 3 audits →