Williams’ death “could have been prevented. Instead, choices were made over and over again to take no investigative or corrective action.”

Inmate X had 18 disciplinary charges between 2012 and 2018, but despite the above incidents he has not faced a formal disciplinary charge since July 9, 2018, when he was cited for possession of a weapon. So he did not face restrictions that would limit his movement or put him under more observation.