Many Suicides in Prisons Could Have Been Averted, Justice Dept. Watchdog Says

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Dozens of inmates, including the disgraced financier Jeffrey Epstein, have died needlessly in federal prisons as a result of lax supervision, access to contraband and poor monitoring of at-risk inmates, according to a report released on Thursday by the Justice Department’s watchdog.

The Bureau of Prisons, responsible for about 155,000 inmates, routinely subjects prisoners to conditions that put them at heightened risk of self-harm, drug overdoses, accidents and violence, the department’s inspector general found after analyzing 344 deaths from 2013 to 2021 that had not been caused by illnesses.

More than half of those deaths were suicides, and many of them could have been prevented if inmates had received appropriate mental health assessments or been housed with other prisoners in accordance with departmental guidelines instead of being left alone, like Mr. Epstein, the report concluded.

The report “identified several operational and managerial deficiencies” that violated standing bureau policies, said Michael E. Horowitz, the inspector general, whose investigators previously concluded that Mr. Epstein’s death at the Metropolitan Correctional Center in 2019 was the result of gross negligence and inadequate staffing.

Investigators found “unsafe conditions” in nearly all the deaths they analyzed, Mr. Horowitz said. The number of such deaths in the federal system has been rising steadily — to about 50 a year, he added.

Despite the prevalence of conspiracy theories about Mr. Epstein’s death, the circumstances were strikingly similar to many of the 187 inmates who died by suicide in the period covered by the report. The overwhelming majority were white men who killed themselves by hanging, many were housed alone when they took their lives and a disproportionate number, 56, were sex offenders — even though a relatively small percentage of federal prisoners are jailed for such crimes.

Investigators cited the overuse of single-inmate cells and restrictive solitary confinement as a significant factor in many suicides. But they said the bureau’s failure to flag serious mental health issues — by classifying troubled inmates as low risk — was an equally serious misstep.

Several deaths cited in the report summed up the systemic breakdowns.

Officials at an unnamed federal prison placed an inmate who had recently tried to kill himself alone in a cell, without his personal belongings or follow-up medical care, even though he had been flagged as a suicide risk upon arrival. In another instance, investigators discovered that a psychological assessment of an inmate who had died by suicide had not been updated to reflect a heightened risk of self-harm and instead was cut-and-pasted from a report filed seven years earlier.

A bureau spokeswoman did not immediately respond to a request for comment.

Mr. Horowitz and his team tried to determine if conditions in federal prisons were worse than those in local and state facilities. But deficiencies in Bureau of Prisons documentation of deaths and the unique composition of the federal population made such a comparison impossible, Mr. Horowitz said. (Most prisoners have been convicted of nonviolent crimes, including immigration and white-collar offenses.)

Many of the problems identified by the inspector general are the result, directly or indirectly, of an acute staffing shortage among corrections officers. The shortage has forced wardens to enlist teachers, case managers, health care aides, counselors, facilities workers and even secretaries to serve as guards, despite having only basic security training.

In that regard, the Bureau of Prisons is not alone. State and local law enforcement agencies around the country, especially corrections departments, are struggling to hire and retain employees at all levels, as higher-paying, less demanding jobs draw away people facing rising housing, food and transportation costs.

Colette S. Peters, the bureau’s director, has enacted several measures to address the issue. But she has had limited success in obtaining major funding increases needed to sufficiently raise salaries or to repair the deteriorating infrastructure at many of the system’s 122 prisons and camps.

Investigators, who conducted site visits and analyzed bureau records, also found stunning deficiencies in the supervision of the 70 prisoners who died of drug overdoses in the period covered by the report.

Prisoners, in some cases, were able to smuggle in opioids using drones flown into prisons at night. Others easily hid drugs in garbage bags after working on cleanup details outside the prison walls.

In one remarkable episode, corrections officers inspecting the cell of an inmate who had committed suicide by overdose found a hidden stash of 1,000 pills that officers had managed to miss during inspections — including one conducted the day before he died.

But drugs were not the only contraband inmates used to harm themselves or others. Officers conducting post-death investigations recovered an array of metal shanks fabricated from nails and spikes, bits of plastic sharpened into blades and garrotes fashioned from bits of cloth and string.

Mr. Epstein, the report noted, accumulated less conspicuous contraband under the noses of corrections officers — sheets and blankets he used to create a noose.

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