It is common knowledge that prisons can be violent, particularly at the highest security level facilities. Inmate-on-inmate and inmate-on-staff violence leads to unsafe conditions for everyone. However, the leading cause of inmate deaths in federal prison is suicide. Mental illness and the loss of hope leads some to take desperate measures to end their lives.
High-profile inmate deaths at federal Bureau of Prisons (BOP) institutions, such as the homicide of James “Whitey” Bulger in 2018 and the suicide of Jeffrey Epstein in 2019, brought national attention to the BOP’s operational and management challenges. The U.S. Department of Justice Office of the Inspector General (OIG) investigations of these deaths identified serious BOP job performance and management failures. Additionally, Congress and prisoner advocacy groups have expressed concerns about the BOP’s efforts to prevent inmate deaths.
OIG announced the release of a new report on issues surrounding inmate deaths in BOP institutions. OIG evaluated 344 inmate deaths at BOP institutions between 2014 and 2021 in four categories: suicide, homicide, accident, and those resulting from unknown factors. Many of the deaths that occurred under accidental or otherwise unknown circumstances involved drug overdoses. Suicides comprised the majority of these deaths, with homicides the next most prevalent.
OIG found that a combination of recurring policy violations and operational failures contributed to inmate suicides, which accounted for just over half of the 344 inmate deaths OIG reviewed. Specifically, OIG identified deficiencies in staff completion of inmate assessments, which prevented some institutions from adequately addressing inmate suicide risks. OIG also found potentially inappropriate Mental Health Care Level assignments for some inmates who later died by suicide. More than half of the inmates who died by suicide were single-celled, or housed in a cell alone, which has been shown to increase inmate suicide risk. The study also found that some institution staff failed to coordinate efforts across departments to provide necessary treatment or follow-up with inmates in distress and that staff did not sufficiently conduct required rounds or counts in over a third of the inmate suicides.
According to OIG’s report, the BOP was unable to produce documents required by its own policies in the event of an inmate death for many of the inmate deaths reviewed. The BOP requires in-depth After Action Reviews, which are meant to be a critical look at the events around the suicide and to provide a roadmap to improve policies to prevent future deaths. OIG found that, “the BOP’s ability to fully understand the circumstances that led to inmate deaths and to identify steps that may help prevent future deaths was therefore limited in assisting OIG in its investigation.”
OIG found that contraband drugs or weapons contributed, or appeared to contribute, to nearly one-third of the inmate deaths, including 70 inmates who died from drug overdoses. Contraband can be smuggled into prisons different ways but sometimes it is the very staff charged with overseeing inmate care that are responsible. In June 2023, Ruben Montanez-Mirabal, who worked as a registered nurse for the BOP at the Federal Detention Center – Miami (“FDC-Miami”) was sentenced to 72 months in prison after pleading guilty to conspiring to receive bribes and introduce prohibited objects, including controlled substances, into a federal prison.
The OIG also found that longstanding operational challenges―staffing shortages; an outdated security camera system; staff failure to follow BOP policies and procedures; and an ineffective, untimely staff disciplinary process―were contributing factors in many of the inmate deaths. These challenges, which have been part of Government of Accountability studies, other OIG studies and Congressional inquiries continue to present a significant and critical threat to the BOP’s safe and humane management of the inmates in its care and custody.
The report represents just one of a number of troubling disclosures about the BOP. Director Colette Peters recently discussed a number of the challenges of the agency on 60 Minutes. As Peters stated in her 60 Minutes interview, "I truly believe in transparency. Are we perfect? No. Do we have issues we need to resolve? Absolutely. But I want people to see the good stuff."
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Article originally published on Forbes.com by Walter Pavlo (Feb 16, 2024)
