CLARKSBURG, W.Va. (WBOY) — Following the high-profile deaths of federal inmates like Whitey Bulger and Jeffrey Epstein, the U.S. Department of Justice’s (DOJ) Office of the Inspector General (OIG) Thursday released an evaluation of issues surrounding inmate deaths in Federal Bureau of Prisons institutions between financial years 2014 and 2021.
Federal Correctional Institution (FCI) Hazelton in Preston County, West Virginia has been in the headlines lately as employees have drawn attention to understaffing issues and a whistleblower raised concerns including abuse and escapes. While the evaluation released Thursday doesn’t include 2022 or 2023, it looked into the deaths of 344 federal inmates at Bureau of Prisons (BOP) institutions, identified “operational and managerial deficiencies” and made 12 recommendations for addressing risk factors the DOJ said contribute to inmate deaths.
The report focuses on deaths due to suicide, homicide, accidents or unknown causes that occurred between FY 2014 and FY 2021. It found that the most deaths in those categories, 17, occurred at U.S. Penitentiary (USP) Atlanta, while USP Terre Haute and USP Hazelton were tied for second at 14 each. The data from the institutions with the most deaths is in the table below:
The evaluation includes break downs of the deaths by causes, inmate and prison security level, housing unit type and more, but the evaluation does not specify how many of each type of death occurred at which institution.
Of the deaths, the OIG said suicide was the most common cause of death, accounting for 54%, or 187, of the 344 inmate deaths. Some of the factors the OIG noted were deficiencies in staff completion of inmate assessments preventing institutions from identifying suicide risks and single-cell confinement, with 86 of the 187 suicides occurring in a restrictive housing setting and 60 of those 86 being while the inmate was single-celled.
Back in February 2021, a BOP official issued a memorandum to all wardens saying the BOP had “experienced an ‘alarming’ number of inmate suicides during FY 2021 and that ‘single celling must stop, particularly in restrictive housing and quarantine, except when approved by the Warden on a case by case basis.'” A task force on single-celling was also created.
The OIG’s report said that as of August 2023, efforts to implement the task force’s recommendations “were ongoing.”
Another issue the OIG addressed was contraband drugs and weapons, which contributed to the death of inmates.
The evaluation said that contraband drugs are entering BOP institutions through inmate mail, books, magazines, staff, visitors and even drones.
Before the evaluation was released, the BOP adopted measures such as photocopying or digitizing inmate mail that does not include legal documents in an attempt to reduce contraband.
Seventy inmates during the period evaluated died of overdoses, with at least 11 of those overdoses involving “misuse of medications that the BOP had prescribed to the inmates,” and two involving medication the inmate had purchased from the commissary. Forty-five of the overdoses were classified as accidental and 17 as suicides.
Thirty-seven inmates died because of contraband weapon use during the period evaluated. Special Investigative Services reported finding weapons made from locks, belts, socks and bed frames. The OIG report said that BOP staff said inmates sometimes melt down polystyrene foam or plastic and mold makeshift knives that won’t set off a metal detector. SIS staff at one unnamed institution “estimated that about 70 to 80 percent of its inmates possessed some type of contraband weapon.”
The OIG evaluation identified issues following BOP policies and procedures surrounding contraband in several inmate deaths, outlined in the table below:
The report reiterated issues surrounding staffing concerns at Hazelton, saying:
At the time of our site visit to Federal Correctional Complex (FCC) Hazelton in November 2021, there was only one Clinical Physician and a contract physician for the entire complex that housed over 3,400 inmates, when the Clinical Director told us that there should be 4 additional staff doctors to adequately provide care for that inmate population. According to one Staff Psychologist at this site, the staffing shortages in Psychology Services forced staff to cover roles and responsibilities of multiple positions, which resulted in an inability to provide treatment to inmates. Separately, another Staff Psychologist who administered the Medication Assisted Treatment (MAT) Program there told us that he could not administer MAT to every inmate who qualified for the program because there were not enough clinicians or medical staff to prescribe and administer the medication. This Staff Psychologist said that he believed that MAT was highly effective in reversing opioid addiction and that he wished more inmates could receive the treatment.
When interviewed, the OIG said that Hazelton staff said some “filled” positions were not being actively staffed due to parental and military leave as well as light duty requirements related to workplace injuries like other institutions reported, but also said Hazelton’s staffing capacity was being impacted by probation and refusals to report for work. FCC Hazelton staff reported during the OIG’s visit that Correctional Officers there could be mandated to work 16-hour days up to four times per week.
“A BOP staffing assessment was beyond the scope of this evaluation, and the BOP has acknowledged that it lacks reliable data on the exact staffing levels it requires at each institution,” the report said.
The OIG issued the following recommendations in the evaluation:
- Develop strategies to ensure that staff assign accurate, consistent, and timely Mental Health Care Level designations to inmates.
- Ensure that all institutions conduct required mock suicide drills, and develop strategies to increase staff participation in those drills.
- Ensure that all appropriate staff are trained in automated external defibrillator use and that automated external defibrillators are strategically placed, readily available, and regularly checked to ensure that they are in working order at each BOP institution.
- Ensure that cut-down tools in working order are accessible to staff in each housing unit at each institution, that staff are trained on proper use of the tool, and that the BOP determines whether staff should be issued and required to keep their own cut-down tool on their duty belt during their entire shift.
- Ensure that each institution has a sufficient number of maneuverable gurneys in strategic locations to provide proper medical response during inmate transport.
- Issue standard, enterprise-wide guidance and training to staff on using the radio to communicate clear, descriptive information during inmate medical emergencies.
- Ensure that staff receive both the initial and refresher naloxone training and are fully prepared to administer naloxone to an unresponsive inmate suspected of having experienced a drug overdose.
- Ensure that all Evidence Recovery Teams are properly trained on post-incident evidence recovery protocols.
- Develop procedures to ensure that all required death-related records are completed and collected consistently and in accordance with established deadlines.
- Assess the benefit and feasibility of expanding its policy requiring After Action Reviews to include reviews of all inmate homicides and deaths by accidental and unknown factors, not just for inmate suicides.
- Clarify responsibility for tracking at an enterprise level the reports and recommendations required in the wake of an inmate death by suicide, homicide, accident, or unknown factors, and assess the information contained therein for broader trends, applicability, and implementation.
- Evaluate existing electronic devices used for inmate screening to identify whether they are functioning as intended, and, if necessary, implement any needed adjustments or upgrades.
Click here to read the full evaluation.
