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Massachusetts Suicide Prevention Procedures Found Lacking

Massachusetts Suicide Prevention Procedures Found Lacking

by David M. Reutter

An independent study of suicide prevention practices within the Massachusetts Department of Corrections (MDOC) has found serious deficiencies in the care of prisoners at risk of suicide. Since 2000, there have been 18 suicides, but 12 of those occurred during 2005-2006. With a 10,500 daily population average, that equates to a suicide rate of 26.9 deaths per 100,000 prisoners, which is almost double the national average of 14.

The study was conducted at MDOC’s request by Lindsay M. Hayes of the National Center on Institutions and Alternatives. He reviewed the investigative and/or mortality reviews of the 10 most recent suicides and visited seven prisons that experienced the suicides.

In each case, Hayes found similarities. He said that 9 of 10 suicides were by hanging in special housing units. Half of the victims were discharged from suicide watch either a few hours or weeks earlier. Six had documented mental health histories and five had previous suicide attempts.

Hayes found MDOC was lacking in what is the key to suicide prevention: staff training of guards. He noted that “[v]ery few suicides are actually prevented by mental health, medical, or other professional staff.” Guards “are often the only staff available 24 hours a day; thus they form the front line of defense in suicide prevention.”

MDOC procedures only require pre-service training, which averages two to four hours, and no annual in-service training. Hayes recommended eight hours of pre-service and two hours of annual training, and that the training regimen be standardized in procedures.

The study also found inadequate identification and screening of prisoners for suicide risk. Hayes said that research of jail and prison suicides reveals a number of characteristics that are strongly related to suicide, including: “intoxication, emotional state, family history of suicide, recent significant loss, limited prior incarceration, lack of social support system, psychiatric history, and various stressors of confinement.”

Hayes recommended that all prisoners returning from court be screened. A brief discharge/transfer form should be created for the sending agency to alert the receiving prison about immediate concerns with a prisoner. Also, any time a prisoner is on mental health watch, it should be documented for future reference, which was not happening during the study. Finally, the highest priority should be to create adequate “alternative housing and programming” for “seriously mentally ill inmates who have co-existing disciplinary sanctions.” Currently, no alternative housing exists.

Deficiencies existed in the three levels or communication that are essential to suicide prevention: “1) between the sending institution/transporting officer and correctional staff; 2) between and among staff (including mental health and medical personnel); and 3) between staff and the suicidal inmate.”

While MDOC maintains a list of prisoners on a “Mental Health Risk list” that is reviewed daily by administration officials, “there is little that currently distinguishes the management of a mentally ill inmate on or off” that list. Hayes recommended that files be regularly audited to determine prisoners on the list, and those prisoners should receive “increased attention” from mental health staff and guards.

Housing of suicidal prisoners was a serious problem. For the most part, such housing is punishment. Rather than clothing being removed commensurate with the individual level of risk, “almost all suicidal inmates (regardless of risk level) are stripped of their clothing and issued safety garments.” Hayes said such decisions should be made by mental health rather than security staff.

The routine loss of family visits, telephone calls, recreation, showers, and attorney visits for suicidal prisoners on watch are anti-therapeutic, said Hayes. The cells also need to be suicide-proofed, rather than have grates and bunk holes that can be used as anchors to hang from. Additionally, mental health staff need to transition prisoners down from mental health watch and conduct interviews privately instead of through cell “food flaps.”

Supervision procedures of suicidal prisoners also needed improvement, as they were varied and inconsistent. When released from watch, mental health staff should continue follow-up assessments. Finally, Hayes found that medical intervention during suicide attempts suffered from systematic problems. In two cases, it took staff 10 minutes to render aid after arrival at the prisoner’s cell. In those cases, staff could not find proper medical equipment. Staff should hold mock suicide training and render aid immediately.
MDOC issued a Corrective Action Plan to implement all of the recommendations in the study report. The report is available on PLN’s website.

Source: Technical Assistance Report on Suicide Prevention Practices Within The Massachusetts Department of Correction

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