Circumstances surrounding the untimely death of Correctional Officer Jayme Biendl at the hands of an inmate are the focus of this incident review. This report “identifies systems, policies, practices, protocol, and technology within MCC/WRS [Monroe Correctional Complex/Washington State Reformatory] which would reasonably have been connected to factors surrounding safety and security for staff and others within that compound” (p. 3). Sections following an executive summary are: pre-planning agenda; documents reviews; staff interviews; briefing and report out; team’s areas of critical review; findings and recommendations for sanitation, staff assaults, treatment/program-custody/control balance, communication and alarm, chemical agents, training enhancement, custody staffing, post orders, inmate movement/call-outs/passes, camera placement and visibility, inmate volunteers, industries and back complex inmate access for jobs/programs/movement, visibility/safety, security audit, current change process, classification review-Inmate Scherf, close custody designated, and staff accountability; and staff comments.