Institutional failures and policy violations by the US Bureau of Prisons (BoP) have contributed to hundreds of preventable deaths of incarcerated people in recent years, according to a federal watchdog report released on Thursday.
The US justice department office of the inspector general (OIG) found that from 2014 to 2021, 187 people died by suicide inside BoP institutions, with the prisons’ psychology services staff reporting that these types of deaths could be prevented if the facilities followed protocols and delivered proper resources and treatment to people in custody. The report also documented 89 homicides and 56 deaths deemed “accidental” during that time period, and said the BoP consistently failed to effectively discipline staff for misconduct that contributed to the deaths.
The scathing report by Michael Horowitz, the DoJ inspector general, paints a picture of a systemic and worsening crisis, and highlights the high-profile 2018 killing of the mobster James “Whitey” Bulger and the 2019 suicide of Jeffrey Epstein. Both deaths were deemed preventable and blamed in part on staff negligence and misconduct. The findings add to escalating concerns about human rights violations within the BoP after the US Senate found that staff have sexually abused women in custody in at least two-thirds of facilities, with some victims abused for months or years.
The inspector general reviewed a total of 344 deaths, finding that 2021 was the deadliest year in the period analyzed, with 57 fatalities, compared with 38 in 2014. Deaths by suicide were most common, making up 54% of deaths in the eight-year period. Stressors that contributed to those deaths include mental health struggles, deaths of loved ones, planned transfers to a different institution, deportation risk, lack of family support and sex offender status, the OIG reported.
More than half of those who died by suicide were isolated in “single-cell confinement” despite well-documented risks of housing people in solitary. The OIG found deficiencies and missed prevention opportunities in more than 40% of deaths by suicide, citing a case in which a person with previous suicide attempts was deprived of personal property items “documented as being important to his ability to cope with living in [solitary]”.
The majority of people who died by suicide had also been classified as the lowest level of mental health needs before their deaths, meaning they were “not required to receive any regular mental health services or to have a treatment plan”. In at least 68 deaths by suicide, the BoP reported that its staff had also failed to complete required rounds; in restrictive housing units, staff are supposed to check on incarcerated people twice in an hour.
The OIG further said that more than 70% of prisons provided no evidence that they had completed required “mock suicide drills”, which are intended to improve emergency response.
More broadly, the OIG found consistent failures in staff response to a range of medical emergencies; in nearly half of all 344 deaths, the OIG documented “significant shortcomings”, including “a lack of urgency in emergency response, failure to bring or use appropriate emergency equipment [and] unclear radio communications”.
The report found there were 78 deaths in which there were problems with defibrillators, including cases where staff did not bring the devices to the emergency, could not locate them or the devices malfunctioned. In 28 deaths, staff did not bring or properly deploy gurneys for transport, the report said.
There were at least 70 drug overdose deaths during that time period, 45 classified as accidental and 17 ruled suicides. Despite the continuing drug crisis behind bars, staff were hesitant to administer naloxone in a timely manner to potentially reverse opioid overdoses, the OIG found. Guards trained to use naloxone were “uncomfortable” doing so, medical staff told the OIG.
The report probably does not capture the full extent of problems that have contributed to preventable deaths. The OIG noted a range of shortcomings in how the BoP gathers and maintains evidence after a death, and that the agency only conducts “in-depth” reviews after suicides.
In 117 cases, the BoP could not produce death certificates for the OIG.
The report recommends training reforms, better strategies to assign mental health classifications and improvements to record-keeping and post-death investigations.
The report comes amid growing scrutiny of medical neglect in prisons and jails across the US, which has the highest reported incarceration rate in the world. Lawsuits have repeatedly uncovered cases in which incarcerated people begged for medical attention and were denied basic care before their deaths and there is a growing crisis of ageing and elderly people languishing behind bars.
Scott Taylor, a BoP spokesperson, said in a statement that the bureau “acknowledge[s] the tragic nature of unexpected deaths among those in our care”, adding: “Our priority is addressing the unique health challenges, including mental health, faced by individuals in custody, particularly those with a higher incidence of substance-use disorders. We are committed to suicide prevention, substance-use disorder treatment, and combating contraband.”
BoP “concurs with the need for improvements”, including enhancing its mental healthcare classifications and is “dedicated to implementing these changes to ensure the safety and wellbeing of those in our custody”, Taylor added.
