On August 20, 2024, the Office of the Inspector General (OIG) for the Nebraska Department of Correctional Services (DCS) released a report detailing its investigation into three prisoner suicides, finding that DCS did not provide psychological autopsies after two, that one took place weeks after a previous attempt by the same prisoner, and that the internal critical incident review (ICIR) in response to the suicides failed to follow DCS policy. 

Just days later, on August 26, 2024, the state’s auditor released a report on DCS for calendar year 2023, which found higher than necessary medical costs, improper handling of inmate trust funds, maintenance fees, debit usage and medication, along with overpayment of DCS staff during a record year for overtime pay.

OIG’s report detailed the unfortunate circumstances around the August 2022 suicide of an unnamed 45-year-old prisoner (referred to as Individual A), who had earlier admitted cutting his wrist with a razor blade after using K2. After that attempt, he was treated at a hospital and put on “Plan A” status, which is DCS speak for suicide watch. But within a week he was back in his usual environment. Last seen by behavioral staff five days after the cutting incident, he was then found in his cell with a bedsheet wrapped around his neck and tied to the top bunk—just 16 days after the initial incident. He was pronounced dead on site.

A suicide note was also found in his cell. But OIG found that the ICIR done in response did not review the wrist cutting incident, nor did anyone review the prisoner’s most recent phone calls or his record detailing past drug abuse. It was alleged that he may have owed money to other prisoners, but no prisoner interviews were conducted.

Another suicide involved another 45-year-old prisoner (Individual B) who in June 2023 was found face-down in his cell with a sheet tied around his neck, late at night while his cellmate was asleep. After paramedics pronounced him dead, his body and his cellmate were placed in a separate holding cell; the cellmate repeatedly told staff that he felt uncomfortable being held so close to the dead body, but OIG found that he was ignored. OIG also later found that Individual B attempted 99 phone calls on the day of his death, only getting through a few times; at one point he was making a call every 3.8 minutes. But there was no video because not all the cameras were working after a system update and “no one checked to see if they were working or not.” OIG noted that there was no attempt by the ICIR to interview Individual B’s cellmate regarding his nightly activities or misuse of medication.

A previous suicide in December 2021 involved a 25-year-old prisoner (Individual C) who had no prior incidents of self-harm or suicide related concerns. OIG determined that the ICIR needed to make sure that proper cell checks take place more often than every 30 minutes, as that gave Individual C time to complete his suicide. 

OIG noted that despite repeatedly requesting psychological autopsies for Individuals A and B, which are required under DCS policy, they were never provided. The report reiterated that the ICIR for all three prisoners failed to interview any other prisoners who may have either witnessed the deaths or had information regarding the decedent’s previous behavior—violating DCS policy, which requires a comprehensive review. The report concluded by recommending that DCS staff wear body cameras in all facilities and review the mostly ignored recommendations of a 2018 suicide response work group. See: Deaths by Suicide; An Investigation of the Deaths of Three Individuals in NDCS Custody, Neb. DCS (Aug. 2024).

Meanwhile, the state auditor found that DCS personnel continue to accumulate at least 40 hours of paid leave each week, even employees working a 36-hour week over four days, resulting in an overpayment of 4 hours. The auditor’s report noted that staff collected leave in 2013-2014 regardless of how many hours were worked, resulting in an overpayment of over $1 million; the problem was addressed then but has been ignored since, leaving workers overpaid by a total of 3,304 hours in 2023, essentially squandering $105,000.

DCS paid $22 million in employee overtime and compensatory time in 2023, over $3 million more than in 2021, the report found. It was not unusual for guards to work an additional 1,000 to 2,000 hours a year on top of their regular paid time—the equivalent of a second full-time job. Such excessive overtime is not only costly but could be “potentially detrimental to the safety of both facility staff and the inmates being watched.”

The cost of medical services for the state’s 5,800 prisoners was called “needlessly high,” too. Over $3.5 million could be saved were prisoners encouraged to enroll in Medicaid, which covers hospital stays even while incarcerated. The DCS central pharmacy also threw away $84,000 worth of unused prescription drugs.

The report further found delays in crediting over $307,000 to prisoner trust accounts from work release employment, a problem DCS had been notified about twice in the past decade. Other findings included $3.4 million in inmate debit card purchases without any review of those transactions.  

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