Conspiracy theories aside, Jeffrey Epstein is one of the latest and most prominent of the hundreds that die by suicide yearly in America’s jails. His untimely death saw the Bureau of Prisons chief fired and caused heads to roll at the federal Metropolitan Correctional Center: the warden of the jail was reassigned, and two staffers were placed on leave. This type of punishment is typical after a suicide in jail, removing a few “bad apples” who may not have been on their rounds, but ultimately not making the jails safer for those who are mentally distressed and in confinement.
Despite the fact that suicides make up one-third of all deaths in jail custody, nearly 63 percent of jails in the United States don’t conduct reviews following a suicide, and few institutionalized responses exist to answer instances of self-harm. In its latest report, “Preventing Suicide and Self-Harm in Jails: A Sentinel Approach” the Vera Institute of Justice partnered with four diverse county jail systems to study how they review and respond to incidents of suicide and self-harm and how they might integrate sentinel event reviews into those jails’ regular practices.
“In layman’s terms, a sentinel event is a significant negative outcome that signals underlying system weaknesses,” says Leah Pope, Senior Research Fellow in Vera’s Center on Substance Use and Mental Health and lead author of the July 2019 study. “So, [it refers to] something that has happened that might look like one fatal error, but is really the result of a series of errors.”
Pope explains that sentinel events methodology has been used for years in other industries such as aviation or medicine—say, after a doctor operates on the wrong leg, or when there is a plane crash, to figure out what went wrong. The sentinel review process is characterized by an “all-stakeholder, non-blaming, and forward-looking” examination of the catastrophe.
Vera researchers spent about four to five days over a year in each of the four jail systems—Middlesex Office of Adult Corrections and Youth Services in Middlesex County, N.J.; Middlesex Sheriff’s Office in Middlesex County, Mass.; Pinellas County Sheriff’s Office in Pinellas County, Fla.; and Spokane County Detention Services in Spokane County, Wash. The jails had the opportunity to remain anonymous until they read the report, but in the end, all chose to be identified.
One of the most interesting parts of the study is that it found that many of those working in prisons feel that suicides are unavoidable; yet, most experts in criminal justice believe that suicides in jails are preventable with the caveat that the jail system must be willing to take a holistic approach in assessing what happened, sharing that information with all involved, and making systemic changes—not assigning blame to individuals (see: Epstein).
“Based on…talking to people, there are definitely situations where jails feel like they did everything they could, that they could not have possibly have anticipated [a suicide],” says Pope. “I think that the contention of real experts in the field is that all suicides are preventable; that it really requires thinking about suicide prevention comprehensively, from the moment someone comes into jail. There are always ways to improve the system—whether it’s through better screening and assessment, whether it’s through the design of the jail, whether it’s through improving communication between systems.”
“The key features or characteristics of the sentinel events approach for review is that they involve all stakeholders who could contribute to the issue and they’re done in a non-blaming and forward-looking way,” says Jason Tan de Bibiana, co-author of the report. “So the idea is not to do a review and conclude that nothing could be done, but to do a review and consider what ways could be improved as a system and as a team.”
The culture in jails, however, is why a lot of its entrenched pathologies seemingly remain intractable.
“I think the issue of culture change in institutions like jails and prisons is huge, and so [it’s about] moving from this ‘bad apple’ approach: ‘Oh it was the CO [correction officer] who didn’t check on the person, or didn’t do their rounds appropriately,’ says Pope. “I think it’s very easy to point fingers; particularly in an industry that’s so litigious; but I also think at least the people we talked to, my sense is that they recognize that that’s not really a sufficient answer, and moving to think about jail suicide under a more systemic level offers the best hope on how to prevent future ones. Because you can get rid of that one CO, but does that really help you think about WHY the check wasn’t performed?”
Tan de Bibiana notes that at the intersection of mental health and jails, there are two related issues. The first is that jails are becoming “sort of the de facto mental health hospitals”; a 2017 survey from the Bureau of Justice Statistics found that 26 percent of people incarcerated in jail met the threshold for serious psychological distress in the past 30 days (compared to 5 percent in the general population). The report also noted that only 35 percent of those in crisis had received mental health treatment since admission to jail.
The other side of the coin is the mental health of those working inside the jails themselves; those employees locked in and constantly being confronted with sometimes severely sick people who sometimes harm themselves or even end their lives.
“One of the things that we didn’t spend a lot of time being able to address in the report but have a lot of data on is jail suicide and self-harm as it relates to officer wellness,” says Pope. “And that certainly wasn’t the frame we went in with—we were primarily concerned with the people who were incarcerated—but I think that’s certainly why it’s such a tough issue because it impacts everyone in the system.
“There’s a lot of evidence pointing to the poor health outcomes of those working in jails and prisons,” she continues. “We did talk to COs and many of them felt both ill-equipped and ill-trained to handle these problems and to respond to them. And then also, if you are involved in an incident in your jail…to have no feedback loop or a sense of what happened or if any changes will happen can be really alienating. So there was definitely in our interviews a sense of this is really difficult for the people who work in jails as well.”
The researchers at Vera say that they sent a series of recommendations tailored specifically to each institution, but will not be working with the jails post-study to implement the recommendations, although there are still ways that the jails can receive resources.
“The National Institute of Justice is continuing its investment in sentinel reviews,” Pope tells us. “They’ve partnered with the Bureau of Justice Assistance to offer technical assistance to jurisdictions across the country who want to engage in these sorts of reviews and there’s an organization at U Penn called the Quatronne Center and they are TTA (training and technical assistance) provider where basically any jurisdiction could apply...And so, we’ve encouraged the jails that we’ve studied to learn about this opportunity and apply if it’s appropriate.”
To read the Vera Report, “Preventing Suicide and Self-Harm in Jails: A Sentinel Approach,” (pdf) click here.