Flawed advice, ignored emails, and a lack of communication allowed the state to continue mistakenly releasing prisoners early for years after the problem was discovered in 2012, according to a report commissioned by Gov. Jay Inslee.

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OLYMPIA — “Calamity of errors.” “Inexplicable failure.” “Incompetence.”

Investigators and Gov. Jay Inslee found choice words Thursday to sum up the delays that for years continued the state’s mistaken early release of prisoners.

Standing somberly in a news conference, Inslee and two former federal prosecutors commissioned by the governor to investigate detailed a report into the long-running sentencing-miscalculation problem.

Key recommendations in governor’s report on early prisoner releases

• Department of Corrections (DOC) should create an ombudsman position.

• Prisoner release dates should be hand-calculated whenever there’s a sentencing-related fix in progress.

• All opinions by the state Attorney General’s Office to DOC should get a supervisor’s review and approval before being sent.

• DOC should restructure its IT governance process.

Source: Investigative report by Yarmuth Wilsdon PLLC

After the problem’s discovery in 2012, a software-programming fix was delayed 16 times — and not ultimately made until this year, after the issue became public.

Inslee harshly criticized those who knew of the problem, but through communication breakdowns and poor judgment, failed to stop it.

If you have the capability to fix the problem, “you have to have a commitment and (be) savvy enough to not allow those people out of jail,” Inslee said, adding: “if they could stop these prisoners from getting out of jail, they should have done it. And they didn’t do it. This is inexcusable.”

The report found no evidence of bad intent, nor any indication that former Corrections Secretary Bernie Warner or current Secretary Dan Pacholke, on the job for just a few months, knew of the problem. Pacholke recently announced his resignation.

But the report called out by name seven state employees investigators say contributed to the delays. The issue was brought to light by the father of a crime victim, who thought his son’s assailant was about to be released too soon.

Inslee called the delay “an inexplicable failure at both an individual and institutional level at the Department of Corrections.”

Officials have said that two people were killed last year by offenders who still should have been in prison. Two people have been charged in those deaths. If current Department of Corrections (DOC) projections hold, 2,800 prisoners since 2002 may have been released before serving their full sentences.

Other prisoners released early and trying to rebuild their lives have been rounded up by DOC to serve the remainder of their sentences.

Inslee on Thursday said he will make personnel changes.

“We are in the process of finalizing those decisions,” he said, adding that employees would first have “every opportunity to tell their story.”

Two people with knowledge of the problem in 2012 already have stepped down.

Meanwhile, an investigation led by a pair of Republican state senators has continued, holding two hearings this week.

The report also outlined eight recommendations, from creating an ombudsman position at DOC to restructuring the agency’s IT governance process.

The report said that the offender release dates should be calculated by hand whenever there’s a sentencing-related fix; and a supervisor from the state Attorney General’s Office should review and approve any opinions from that office to the DOC.

While the investigators didn’t pinpoint a reason for the delay in solving the computer-software problem, they laid out a series of miscommunications and judgment calls that stymied progress.

“The list goes on and on and on; that’s incompetence,” said Carl Blackstone, one of two former federal prosecutors of the Seattle-based law firm Yarmuth Wilsdon who conducted the investigation. He added later: “It’s not intentional, it’s not malicious, it’s just a calamity of errors.”

Communication breakdown

The result of a nearly two-month investigation, the report compiles a bevy of bureaucratic problems that allowed for the continued early release of prisoners for years after the problem’s discovery.

The highest-ranking DOC employee who knew of the problem at the time was Denise Doty, an assistant Corrections secretary who reported directly to Warner.

There was “ample evidence indicating that Denise Doty was aware of the problem and failed to address it,” according to the report.

Doty, who in 2015 went to work for the Office of Financial Management, resigned this month.

Although Doty was been the top person to know of the problem, the investigation concluded that IT business manager David Dunnington, “bore primary responsibility for repeatedly delaying the IT group from fixing the early release problem.”

As the person prioritizing fixes for a database known as OMNI, Dunnington “clearly understood that OMNI was miscalculating release dates for [some] offenders,” according to the report.

Dunnington couldn’t explain to investigators why he delayed the programming fix, according to Blackstone. And Dunnington didn’t make notes revealing his decisions not to prioritize it, Blackstone added.

But it’s believed that Dunnington did not receive emails that might have explicitly alerted him that hundreds of offenders were at risk of being released.

Those emails started circulating in December 2012 with an email memo from an assistant attorney general to a DOC staffer.

Writing to DOC records administrator Wendy Stigall, Ronda Larson advised the issue wasn’t so urgent as to require staff to hand-calculate prison sentences to stop early releases.

“It would be reasonable to not manually fix the hundreds of sentences … and instead wait for the reprogramming” of the software, Larson wrote in that email.

The report called her advice “deeply flawed for a number of reasons” and Larson recently announced her resignation.

Stigall forwarded Larson’s email to the agency’s risk-management director, Kathy Gastreich, who never responded to it, according to the report. Gastreich “has no recollection of this email and claims she was not aware of this problem until very recently.”

Even though Stigall did a good job alerting people to the problem early, according to the report, she “appears to have done little to nothing in the intervening period of almost three years to get this problem corrected.”

The report concluded that in addition to Pacholke and Warner, no one in the governor’s office knew of the problem before mid-December.

Warner, who left the department last year and now works in Utah, did not return calls or emails seeking comment.

During the news conference, Inslee’s counsel, Nick Brown, said Warner shared some responsibility for the atmosphere at DOC that allowed the problem to exist for so long.

“I feel very confident based on how I have interacted with Secretary Warner in the past that he feels bad about this,” Brown said.

But, “there is some apathy here around recognizing the severity of this problem,” Brown added.

‘Systemic problem’

The report’s release came hours after a state Senate committee held its latest hearing in a Republican-led investigation.

At the hearing, DOC’s Chief Information Officer Ira Feuer said the agency had communication problems that likely contributed to the failure to make a software fix.

“I’m not really sure anyone knew who was making decisions in prioritization” of IT solutions, said Feuer, who began work at the agency in August. “It didn’t seem to be just one individual … it was a systemic problem.”

But even in late November, “I didn’t know the magnitude of the problem,” Feuer said. in mid-December Feuer learned the sentencing miscalculations potentially affected thousands of prisoners.

That awareness came only when enough of a software coding fix had been completed for the agency to run a simulation to determine who would be affected.

The simulation “pulled up thousands of names,” he said. “I knew that was critical at that point.”

Thursday’s hearing also revealed that the Senate removed an attorney working on the investigation after that attorney emailed Feuer.

Monte Gray, who works for Davis Wright Tremaine, the law firm contracted by the Senate to help with the investigation, asked Feuer about personnel actions that could be taken.

In the email, Gray suggested three DOC workers who might lose their jobs after Inslee’s investigation is released and noted that others involved in the sentencing problem already have stepped down.

After stating he had “strong opinions” about “throwing those three under the bus,” Gray wrote Feuer: “I’d be interested in your views and how much you’d be willing to say publicly.”

Feuer told lawmakers he found the email “strange” and reported it to his superiors. Sen. Mike Padden, R-Spokane Valley and chairman of the Senate Law and Justice Committee, apologized to Feuer and said Gray had been removed from the investigation.

For his part, Padden remained nonplussed by the governor’s investigation.

“The whole story’s not really been told,” Padden said in a news conference after the report had been released.

Warner deserves blame, Padden said, for how the agency was managed.