Randy Liebich curled up in a ball on his bed inside Stateville prison, about an hour outside Chicago. It was June 2010, and he’d spent the night in a cold sweat, excruciating pain radiating from his back. For months, he’d been filing complaints with prison officials about the lack of medical care. But the forms, known as grievances, got him nowhere.

One was denied, in part because he’d already been to the doctor, and the denial noted he’d received acetaminophen pain medication. Another complaint was deemed moot.

Now Liebich was in the worst pain of his life. According to medical records, a kidney stone had made it impossible for him to urinate. The men in nearby cells shouted for help.

Correctional officers took Liebich to the medical office, where, records show, a doctor used a hemostat, a tweezer-like surgical tool, to try to remove the stone through the tip of Liebich’s penis. But the procedure failed, leaving the stone intact. About six hours passed that day before Liebich was driven to an outside hospital for emergency surgery.

When Liebich got back to the prison, he filed two more grievances about the poor medical treatment he’d received. If staff had addressed his earlier complaints, he wrote, he could have avoided the procedure with the hemostat altogether. But prison officials denied those grievances too.

Liebich filed over a dozen more grievances related to his kidney condition over the next eight years, until a judge threw out his murder conviction in 2018 after finding his lawyers ignored key evidence. Prosecutors later dropped all charges, but Liebich says he still suffers trauma from his experience with the hemostat.

People locked inside prisons rely on grievances to complain if their needs, from health care to sanitation to safety, are unmet. The complaints are among their few means of recourse. But in Illinois, that system is sputtering, with little oversight, leaving prisoners vulnerable to harm, an investigation by WBEZ and ProPublica has found.

The state has paid millions to settle the claims of inmates, some of whom raised concerns early through grievances, only to later suffer serious injuries when authorities denied complaints or failed to act.

In one case, a prisoner at Stateville Correctional Center filed a grievance to complain about roaches crawling over him as he slept. He also said he had extreme pain in his ear and heard constant crackling. But he said his complaints were ignored by prison staff. Two weeks after his grievance, records show medical workers removed a bug from his ear. He later filed a lawsuit, alleging ear pain and hearing loss. The case was settled for $12,500, three and a half years after the first grievance. The state denied wrongdoing.

In another case, a man at Stateville spent months filing grievances and writing letters to prison officials about a protruding bolt near his bunk bed. The warden denied the grievances, because they’d been filed as emergencies, and he disagreed with the classification. Eight months after the prisoner’s initial complaint, he fell out of his bed and hit his eye on the bolt, resulting in “disability and disfigurement,” according to a lawsuit he filed. Records show he was treated by a doctor the same day. The state disputed the man’s claims in court documents, but the parties agreed to a settlement in which the state paid the inmate $70,000.

In Liebich’s case, he filed a lawsuit over the medical treatment he received and alleged that prison staff retaliated against him for complaining. The state denied wrongdoing but agreed to a settlement of $70,000.

The Illinois prison system, which had an average daily population of about 40,000 people last year, is now under federal oversight as part of a legal agreement to improve health care in state prisons. A court-appointed expert found in 2018 that the medical care was so poor that people were needlessly dying.

Because grievances can serve as early warnings for prison administrators about dangerous conditions, experts say tracking the complaints is critical.

But WBEZ and ProPublica found Illinois is faltering. The news organizations requested five years of data from the 15 largest prisons, showing the number of grievances and how they were resolved. Only seven were able to provide information that was complete enough to analyze. Some institutions had an entire year of data missing.

Of the grievances that were reviewed by prison officials, about 5% were decided in part, or in whole, in a prisoner’s favor. Inmates can appeal to a Department of Corrections review board, but the approval rate there was similar, the WBEZ-ProPublica analysis found.

States have different methods of tracking grievances, and it’s difficult to compare Illinois’ system to other jurisdictions, but experts said the findings suggest it’s not working as it should.

“With a rate that low, it just seems like nobody believes in the system,” said Dan Pacholke, former administrator for the Washington State Department of Corrections and co-author of a book on prison safety. “It would certainly be concerning for me … as a superintendent of a prison.”

Others were more blunt.

“What we have here is sort of the fox watching the henhouse,” said Jenny Vollen-Katz, executive director of the John Howard Association, an independent citizen group that has monitored Illinois prisons for more than a century.

WBEZ and ProPublica sought an interview with state corrections officials over the course of four months, but the department declined multiple requests. In a written response, it said the approval rate appeared artificially low, in part, because of prolific grievance filers and frivolous complaints. It also noted that many grievances are resolved informally by counselors; about 13% of grievances in the analysis were withdrawn by the inmate before an official review.

Still, in response to a detailed outline of our findings, corrections officials said they were pursuing a number of measures to improve the grievance system, including plans to hire a chief inspector to oversee the statewide system. Officials also said the department would be transitioning to electronic grievances, a move that would make the system more efficient and data easier to track.

“The operation of a fair and consistent grievance process is a high priority for the Department, and we are working diligently to improve the current system,” the department said in the statement. “Through the implementation of significant reforms and an increase in oversight, we can ensure the concerns of men and women in custody are addressed in a timely manner.”

Prison watchdog groups and some lawmakers lauded the changes, but they said Illinois’ system needs a bigger overhaul with more oversight. Some are pushing a proposal to create an ombudsman that would investigate complaints about the department.

Illinois State Rep. La Shawn Ford, a Democrat and former head of the House Restorative Justice Committee, said family members of people in prison regularly call his office asking for help with a grievance. He commended the department’s proposed changes but said officials need to “make sure that there’s a process in place that will allow for the best outcomes for the people making grievances.”

“You cannot be the judge and the jury and the prosecutor.”

“A Safety Valve” for Inmates

In the fall of 1971, nearly 1,300 prisoners took over Attica Correctional Facility in New York to protest abuse and poor living conditions. It was one of the most violent prison standoffs in U.S. history, leaving 43 people dead. Over the next few years, other prison uprisings broke out across the country, as the prison rights movement grew. A report from the U.S. Department of Justice said the lack of grievance systems had probably made these incidents “inevitable,” because prisoners had no other way to get their needs heard.

Toussaint Losier, a professor of Afro-American studies at the University of Massachusetts-Amherst who has studied American prisons, said grievance systems emerged in this era to create “a safety valve” to “let off some of the steam that could build up over time.” But states also had another incentive. Lawsuits filed by prisoners were clogging the federal court system; by 1974, 1 in 20 civil cases filed in federal court were prison civil rights cases, according to Margo Schlanger, a professor of civil rights law at the University of Michigan and a leading expert on prison litigation. Federal judges called for another venue to evaluate complaints. As one put it, if prisoners had a fair alternative, they’d choose that over the “delayed process of the courts.”

But even after states created grievance systems, the deluge of lawsuits continued. A study from the early 1980s found people incarcerated at two Illinois prisons thought the state’s grievance system was “wholly institution controlled and rarely yielding favorable or even impartial results.”

To stem the tide of lawsuits, Congress passed the Prison Litigation Reform Act, or PLRA, in 1996. The legislation made grievances critical by requiring inmates to exhaust the prison’s internal grievance system before filing a lawsuit. A co-sponsor of the bill, Sen. Strom Thurmond, R-S.C., said it would “prevent frivolous and malicious lawsuits filed by prison inmates.” Opponents, including then-Sen. Joe Biden, D-Del., argued the bill unwisely limited the court’s power to protect the constitutional rights of people behind bars. The results of the law were striking. The number of lawsuits filed per prisoner shrank by more than 50% over the next two decades, according to Schlanger.

But that’s not because prisoners’ problems were suddenly being addressed through grievances. In fact, some experts say the PLRA may have actually made grievance systems worse. After the law passed, some corrections officials raised administrative hurdles for the complaints, and in doing so made it harder to file lawsuits. Schlanger said prison officials in some states threw out grievances for tiny technical violations, like writing in the wrong color ink.

In Illinois, the state Department of Corrections reduced the window of time within which prisoners can file most grievances from six months to 60 days. It also limited outside oversight of appeals, eliminating a rule that required at least one review board member to come from outside the department. The agency did not respond to a question about the changes.

But officials did note that one reason the approval rate of grievances is so low is because prisoners make technical mistakes, like missing a deadline.

“There was a huge incentive to make the grievance process as complicated and as impossible to complete properly as they could,” said Alan Mills, a lawyer and executive director of the Uptown People’s Law Center who has spent decades representing prisoners in Illinois.

Instead of protecting prisoners’ rights, Mills said grievance systems instead work to protect the department and its employees from lawsuits. In 2011, Mills was part of a team that filed a class-action lawsuit on behalf of deaf and hard of hearing prisoners who weren’t getting hearing aids or access to interpreters. The plaintiffs argued that they were unable to participate in education programs, stay in contact with loved ones or discuss medical issues with doctors. Mills estimates it took lawyers 18 months to figure out how to exhaust the grievance process so they could move forward with the lawsuit. For example, Mills said, sometimes prison officials would only respond to one issue in a grievance even if a prisoner had listed several issues. This made it unclear if the other issues had been denied, ignored or granted — leaving the prisoner unsure if they needed to file additional grievances.

“This is 10 extremely qualified, experienced lawyers trying to figure out how to navigate this process. Imagine what somebody who dropped out of sixth grade and is sitting in a jail cell with no resources at all; how they can ever figure out how to make it through that process?” Mills said.

The lawsuit later settled with the state agreeing to provide accommodations for deaf and hard of hearing prisoners.

Disappearing Grievances, Frustrated Prisoners

In the spring of 2011, officers at Lincoln Correctional Center ordered about 200 women out of their housing unit. Wielding batons and shields, officers marched the prisoners into a gymnasium and conducted a series of strip-searches, according to a lawsuit the women filed in federal court.

The women were then forced to spread their buttocks and vaginas in view of male staff, and officers made derogatory comments about their bodies, according to the lawsuit. The women, who alleged the search constituted cruel and unusual punishment, also said they were forced to remove tampons and bled on themselves while they waited for others to be searched.

A lawyer for the Department of Corrections denied those claims of mistreatment and said the search was necessary to keep the facility safe from contraband. A jury decided against the prisoners, but the women appealed on different constitutional grounds and that case is ongoing.

Dozens of the women said they filed grievances over the strip-search. But as time passed, many didn’t get an answer. Later, the nonprofit John Howard Association conducted a monitoring visit to the prison. According to its report, the group said it heard “a significant number of consistent, unsolicited, and independent reports” about the strip-search and missing grievances. But the group said that when it asked prison administrators about it, they could not locate a single grievance related to the incident. Nevertheless, the nonprofit’s report said officials there acknowledged problems with the grievance system and said they made changes to improve tracking.

Maggie Burke, a former state corrections official who retired as warden of Logan Correctional Center in 2017, said grievances routinely disappeared. “If it was just an occasional ‘my grievance disappeared,’ ... I would think that it was someone who was exaggerating,” she said, adding, “But it happened a lot.”

The problem was so bad that when she became the statewide coordinator for women and family services within the department — about two years after the strip-search incident — she added locked boxes that only she and her assistant could access. That gave prisoners a direct and more secure way to express concerns or send her grievances.

The system is critical, Burke said, because people may act out violently or create other problems when their grievances aren’t addressed.

Dwaine Coleman said that’s what he did while incarcerated at Vienna Correctional Center in 2014 for marijuana possession. He complained of excruciating back pain, and prison records show he had previously been diagnosed with sciatica. But he said a doctor did little more than tell him to eat well and exercise. So he filed a grievance asking to see another doctor.

A month passed before a corrections counselor wrote that the care Coleman was receiving was appropriate, and the grievance went up the chain of command. Two weeks later, he had yet to get a decision from the warden. Desperate to grab the attention of senior prison officials, Coleman tied his prison-issued bed sheet in knots and began flushing it, bit by bit, down the toilet. The water gushed over the bowl, flooding his cell, according to court records.

“The grievance system is a joke. So you kind of have to act out to get your needs met,” Coleman said in an interview. “When you start to act out, there are incident reports that have to be sent all around, and now there’s a paper trail and a lot more people are getting involved.”

Coleman said his attempts backfired though — and tensions between him and the staff continued to escalate. A few days after the toilet incident, Coleman said he got into an argument with a correctional officer during a medical evaluation, according to a lawsuit he filed. On the way back from the health care unit, Coleman alleged, the officer rammed his head into a doorway. A dental record from about two weeks later shows a chipped tooth. During a civil trial, the officer denied assaulting him. But a jury decided in Coleman’s favor and awarded him $35,000 in punitive damages.

Coleman did eventually get a decision from the warden on his health care grievance — three months after he filed it. The complaint was denied, saying the care he received was appropriate.

“Fear of Retaliation”

Few prisoners in Illinois have faith in the grievance system. Just 5% considered it effective, according to a 2019 survey by the John Howard Association, which collected responses from 12,780 prisoners across the state. And only 13% said they felt comfortable filing a grievance.

“The biggest reason that people don’t feel comfortable is fear of retaliation,” said Vollen-Katz, executive director of the watchdog group.

After Liebich filed grievances complaining about the poor medical care he’d received for his kidney stone, he said staff began to view him as a nuisance. In January 2011 officers came to his cell and, according to court records, insisted that he give a urine sample for a drug test.

Liebich told the correctional officers that his kidney condition made that difficult. Officers told him that if he didn’t urinate in the next two hours he’d be sent to the “hole,” officially known as segregation. It’s a part of the facility where prisoners are sent as punishment, infamous for being filthy, full of bugs and vermin. (In fact, the conditions were so bad that officials shut down that section of the prison in 2016, though it was reopened for COVID-19 quarantining this year.) For Liebich, the pressure to provide a urine sample felt immense. So, with minutes left to his deadline, he asked if he could have more time.

The guards refused and took him to segregation, according to prison records. Because staff knew his trouble with urination, he believes the whole incident was meant to punish him for filing grievances.

Liebich’s lawyer sent emails to the warden, letting him know about Liebich’s medical condition. But according to records provided by the lawyer, the warden responded that Liebich would need to address his problem through the grievance process.

Five days after the drug test incident, Liebich filed a complaint over being sent to segregation. The officer that reviewed his grievance recommended the warden approve it, according to prison records, but the warden disagreed and Liebich remained in segregation. Still, in August 2011, Liebich pressed forward with a lawsuit alleging poor medical treatment and retaliation. In court documents, prison officials agreed that Liebich was sent to segregation for failure to provide a urine sample, but they denied that officers were acting in retaliation.

The state agreed to a settlement of $70,000 in January 2015, four years after Liebich filed his grievance over his punishment.

Calls for Transparency and Oversight

Civil rights lawyers, former prison administrators and prisoners say the only way more people behind bars will get their concerns addressed is with independent oversight and increased transparency.

Currently, the entire grievance process is overseen by the Corrections Department.

Grievances first go to a counselor who attempts to resolve the complaint. If they cannot, a grievance officer evaluates the case and makes a recommendation to the warden, who renders a decision. If a prisoner is dissatisfied with the response, they can send their complaint to a statewide board that reviews grievance appeals called the Administrative Review Board.

The whole process can be time consuming.

The state Corrections Department would not say if it had any data showing the speed at which prisons resolved grievances. Records, however, suggest that many complaints were reviewed slowly, or not at all. Over a third of appeals were thrown out because the prisoner had already been released or died by the time the review board evaluated them.

Of those that were reviewed, 7% were found partially or wholly in favor of the prisoner. The panel evaluates thousands of grievances a month. Complaints can range from a missing radio to guard abuse.

“When you’re seeing that many grievances, it’s easy to go, ‘Yeah. OK. You know, that one I don’t really have time for,’” said Joni Stahlman, former assistant deputy director of the women’s division who sat on the Administrative Review Board in the early 2000s. “There’s that tricky line of fairness and getting the work done.”

Prison advocates point to a more fundamental issue though: While the four members of the board do not work at any individual prison, they are still employed by the Corrections Department and appointed by the director. Sitting on the current board are two members who previously worked clerical jobs within the department and one who formerly worked inside a prison as a correctional counselor. Vollen-Katz, of the John Howard Association, said that’s not true independence. “We are asking a closed system to police itself,” she said.

Vollen-Katz said one step the state could take would be to create a corrections ombudsman who could investigate complaints and find solutions. Mills, the civil rights lawyer, agreed, saying the Illinois Department of Juvenile Justice already has such a person who “gets copies of all the grievances so that they can track them, find trends, figure out problems, and then bring them to the attention of the department ... to fix.”

An ombudsman in the adult system, he said, “would be a huge, huge step forward.”

In order for it to be effective, though, the position would need complete autonomy, enforcement capabilities and the power to share information with lawmakers and the public, advocates said. Other states, like New Jersey and Washington, already have a corrections ombudsman, and last year Illinois state lawmakers submitted a bill to create one. But the legislation stalled.

Illinois State Rep. Rita Mayfield, who co-sponsored the ombudsman bill, said she planned to revive the legislation next year. She said one of her central motivations was discovering and fixing problems before they become expensive lawsuits.

“What can we do to reduce these losses? What is wrong with the system? What can we correct to better utilize those tax dollars?” Mayfield said. The Department of Corrections would not answer questions about its stance on an ombudsman.

Losier, the professor who has studied prisons, said another key change to the grievance system should be more transparency. New York state, for example, issues yearly reports on what types of grievances are filed and how the department handles them. That allows the public and lawmakers to monitor what’s happening inside. But Illinois issues no such report.

New York’s Corrections Department also maintains a database that tracks staff involved in misconduct and abuse claims, so the department can look for patterns. But in Illinois, despite records showing staff misconduct is one of the largest issues for prisoners, the department doesn’t track grievances by guard name.

Burke, the former warden, said that having that information, even internally, would be helpful. “If we have, you know, ‘90% of our grievances are on one person,’ then we know that there’s a problem there.”

Pacholke, the former administrator for the Washington State Department of Corrections, agreed, saying data collection is critical. “If you’re not tracking it, the next thing you know, something really horrific or tragic can happen,” he said.

Neither the Corrections Department nor AFSCME, the union that represents most front-line corrections staff, responded to questions about the potential of tracking complaints about correctional officers.

“There’s Nobody That We Can Really Go to for Help”

In Liebich’s case, problems within the prison persisted.

In January 2018, after his lawsuit was settled, the staff decided to test him for drugs again, according to discipline records. When he couldn’t provide a urine sample, officers sent him back to segregation.

“They just went through this with me. They know I have these medical issues,” Liebich said in an interview. “They know I had a civil suit about it, and they turn around and they did the same thing to me again.”

Liebich spent his days in a cramped cell. The prison allowed inmates to leave their cells for mental health groups. Liebich said sessions were held in the former execution area, from when Illinois had the death penalty.

“You can literally feel the hairs on your arms and your neck stand up,” Liebich said. He felt powerless.

In January 2019, Liebich filed a second lawsuit against the prison over retaliation. Later that year the state agreed to settle and paid him $25,000, but denied wrongdoing.

Today, he said he still has nightmares about his time inside segregation.

“It’s frightening to think that they can do this to us and get away with it,” Liebich said, “and there’s nobody that we can really go to for help.”