New watchdog report looks at issues connected to federal prison suicides

There were 187 inmates that died by suicide from 2014 to 2021, the Justice Department Inspector General concluded in a report released on Thursday, raising concerns about excessive contraband behind bars, failures of mental health care and other "challenges."

In the seven-year period analyzed by the new report, 344 inmates died in BOP custody from suicide, homicide, accidents or unknown causes, according to the inspector general. More than half of those deaths were by suicide.

The inspector general's nearly 100-page report found that staffing shortages, a lack of policy and a lack of adequate communication made all of the deaths at least somewhat preventable, the inspector general found.

"We also found instances of potentially inappropriate mental health care level assignments for some inmates who died by suicide, as well as deficiencies in staff completion of required mental health assessments," Inspector General Michael Horowitz said in a video released by the office.

"Additionally, we found that contraband drugs and weapons contributed to many of the inmate deaths in our scope, including for the 70 inmates who died of drug overdoses. Other long-standing operational challenges also contributed to many inmate deaths, such as staffing shortages, an outdated security camera system and an ineffective, untimely staff disciplinary process."

These systemic concerns were brought into the spotlight after two high-profile inmate deaths: in 2018, when notorious mobster James "Whitey" Bulger was killed at at a federal facility in West Virginia; and in 2019, when disgraced financier and sex offender Jeffery Epstein, who had been accused of a sprawling sex trafficking conspiracy, died by suicide while in custody in Manhattan.

Epstein, the inspector general has found, used a bedsheet to hang himself. He is one of the 157 inmates who died by suicide through hanging from 2014 to 2021.

More factors

A failure to manage inmates at risk of suicide is one of the issues the new report identifies.

When inmates enter into BOP custody, they are given a number from one to five -- least to most -- to determine if they need mental health treatment.

One-hundred and eighteen of the inmates who died by suicide were given a number 1, which indicated there were no mental health indicators that were concerning to staff at the facility.

"Our review of the BOP's records on inmate deaths identified various shortcomings relating to the management of inmates at risk for suicide, and the BOP specifically identified staff training deficiencies or the need for additional staff training in approximately 42 percent (144 of 344) of inmate deaths, including 94 suicides," the watchdog report states.

Of the 187 total inmates who died by suicide, 102 of them were in restrictive housing units, according to the inspector general.

A federal penitentiary in Atlanta had the highest number of inmate deaths over the course of the seven years, with 17.

The inspector general found that before some inmates died by homicide or suicide, staff failed to search or did not sufficiently search housing units or inmates cells.

In another instance, the inspector general found that BOP staff purported to check the cell of an inmate who had 1,000 pills in his cell -- and overdosed the next day.

Additionally, 89 inmates were murdered in prison -- primarily using illegal contraband, which the inspector general said is at "an all time high."

"To properly respond to high-stress, potentially life-threatening inmate emergency conditions such as hanging, attempted homicide or drug overdose, BOP staff must be prepared to promptly follow correct protocols and use proper, easily accessibly functioning equipment," the report states.

Weapons, according to the inspector general, significantly contributed to inmate deaths: 37 inmates died from a contraband weapon, such as a makeshift knife.

In a letter attached to the report, the BOP director, Collete Peters, responded to 12 recommendations made by the inspector general.

The recommendations range from better training for staff to increasing technology at the prisons.

"Any unexpected death of an adult in custody ... is tragic. As noted in the OIG's report, we have already taken many steps to mitigate these deaths and we welcome OIG's recommendations as a way to further our efforts," Peters wrote.

While she noted that "Individuals in our care have often engaged in high-risk activities prior to incarceration that predispose them to acute and chronic illness," she also wrote that "it is a priority for" her bureau "to address the physical and mental health needs of those in our care and custody."

Editor’s note: This story has been updated to add more context about the inspector general’s report and correct descriptions of total federal inmate deaths.