Bureau of Prisons Failures Contributed to Inmate Deaths: Inspector General

A new report from the Department of Justice Office of Inspector General (DOJ OIG) indicates mismanagement and chronic understaffing at the Federal Bureau of Prisons (BOP) are often contributing factors in inmate deaths.

The DOJ OIG reviewed the deaths of 344 inmates from fiscal year (FY) 2014 to FY 2021, and directly blames staffing problems for 30 deaths.

Out of the deaths, more than half were suicides, about 90 were homicides, and 68 were from accidental or unknown causes.

“The OIG identified several operational and managerial deficiencies that created unsafe conditions prior to and at the time of a number of these deaths,” stated the report.

The staffing issue was particularly striking with suicides, as the report stated that lack of staff in health and psychological services led to a decline in care for mentally ill inmates. In addition, staff were faulted for not picking up on suicide warnings, as well as not receiving proper training in suicide response efforts. Half of the suicides also occurred in restrictive housing, despite only eight percent of inmates living in such cells.

The report also faulted BOP for numerous other issues, many of them tied to the overall challenge of staff shortages:

·         Insufficient response to emergencies due to lack of communication, urgency, or proper equipment, with the report noting that “Significant shortcomings were found in emergency response to nearly half of inmate deaths reviewed.”

·         Failing to produce documents about inmate deaths as required by BOP policies. That includes failing to conduct in-depth reviews for inmate homicides or accidental deaths, and instead only requiring them on suicides. “The BOP’s ability to fully understand the circumstances that led to inmate deaths and to identify steps that may help prevent future deaths is therefore limited,” stated the report.

·         Insufficient monitoring for contraband due to staff shortages and outdated security camera systems.

The report also noted that staff is facing chronic overtime and is often being reshuffled leaving some critical jobs unfilled at times.

In response, BOP Director Colette Peters concurred with the report’s 12 recommendations and called the overall report “thoughtful.”  Director Peters also noted that misconduct comes from a “very small percentage of the approximately 35,000 employees . . . who continue to strive for correctional excellence every day.”

Meanwhile, Inspector General Michael Horowitz sent a separate management advisory memo to Director Peters repeating the report’s findings over document retention.

This after OIG found that corrections officers falsified records about doing their rounds, after an inmate’s death.

The OIG is recommending that BOP set up a single set of standards for documenting rounds in special housing units.


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