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DOJ report sheds light on federal inmate deaths

Following the high-profile deaths of federal inmates James “Whitey” Bulger in 2018 and Jeffrey Epstein in 2019, as well as several inmate homicides at the United States Penitentiary (USP) Hazelton in Bruceton Mills and USP Thomson in Illinois, the U.S. Department of Justice (DOJ) Office of the Inspector General (OIG) initiated an evaluation to assess the circumstances surrounding inmate deaths at Federal Bureau of Prisons (BOP) institutions. 

The recently published report found that across the country the BOP failed to prevent the deaths of 344 inmates over the course of eight years (2014-21), including 14 at USP Hazelton, the second highest amount of any BOP institution in the country. USP Hazelton is one of three facilities within the Federal Corrections Complex (FCC) Hazelton, which also includes a female facility and a medium-security Federal Corrections Institution (FCI). 

USP Atlanta had the most over that time period but has since been lowered from a medium-security facility to a low-security facility. USP Terre Haute in Indiana also had 14 deaths in the eight years. 

The OIG report details their analysis of the frequency and pattern of deaths among BOP inmates from 2014-21, breaking them down into four categories — suicide, homicide, accidental and unknown factors. They also identified potential management deficiencies and systemic issues related to those deaths and made 12 recommendations to assist the BOP in addressing contributing factors. 

The majority of the deaths reviewed by the OIG were suicides, accounting for 54% or 187 deaths — just over half of the 344 total. 

Homicides were the second-most-prevalent cause of death at 89, followed by accidents at 56 and unknown causes at 12. The report clarifies that while the accident category includes aspiration and other accidents, the majority of deaths placed in the accident and unknown categories involved drug overdoses. 

The report stated that most of the inmates who died were housed in general population settings; however, “39 percent of inmates who died by homicide and 46 percent of inmates who died by suicide were housed in a restrictive housing setting. As of August 2018, throughout the BOP about 92 percent of inmates were housed in a general population setting and approximately 8 percent were housed in a restrictive housing setting.” 

During their analysis, investigators found “significant recurring issues and contributing factors” to inmate deaths, including inadequate staff response to inmate emergencies, failure to properly assess, manage and monitor inmates at risk for suicide, and deficiencies in the BOP’s ability to collect, maintain and learn from evidence and post-incident documentation.  

They found that other long-standing and well-documented challenges in BOP operations, including contraband — both weapons and drugs — security camera coverage and understaffing, “further exacerbated these conditions and hindered the BOP’s ability to control the risk of death among inmates in its custody by suicide, homicide, and other causes.” 

Staff at the Hazelton facility have been speaking out about understaffing issues and the amount of mandated overtime, which they fear could create a dangerous situation. The facility has been short an average of 75-80 correctional officers (COs) over the past year. 

Staff interviewed by investigators at various BOP institutions expressed the belief that due to understaffing COs were overworked, less vigilant and conducted fewer rounds. 

In the report investigators stated, “a Correctional Services supervisor at one institution that we visited described overworked staff as ‘walking zombies’ and a security risk.”  

U.S. Sen. Joe Manchin made various efforts throughout 2023 to promote staff and inmate safety at Hazelton and all federal prisons, including letters penned to BOP Director Colette Peters, urging her approval of a 25% retention incentive for Hazelton staff and another urging an investigation of the conditions at Hazelton to Attorney General Merrick Garland, Deputy Attorney General Lisa Monaco and Peters. 

Manchin called the findings of the OIG report “disturbing” in a statement released Thursday. 

“I am deeply disturbed by this new report on inmate deaths in federal prisons, including at West Virginia’s FCC Hazelton facility,” the senator stated. “It is far past time we pass legislation to improve oversight and increase transparency to protect both the people working in these facilities and the individuals incarcerated in the federal prison system.  

“We also must address the severe staffing shortages that exacerbate these dangerous environments,” he continued. “In November 2023, I called on BOP Director Colette Peters to approve a 25-percent retention incentive for all staff in good standing at FCC Hazelton, and I renew this request.  

“Today’s report should be a call to action and makes crystal clear that adequate staffing is essential for creating safer and more-secure conditions for staff and inmates. While I will continue working with my colleagues to advance commonsense reforms, I call on Director Peters to quickly approve this request.” 

The press release from Manchin’s office highlighted some other findings indicated in the report, including that during the period studied COs at FCC Hazelton were mandated to work 16-hour days up to four times per week.  

Hazelton also relies on “augmentation,” a practice in which non-CO staff, such as counselors, plumbers, cooks and teachers are required to work as COs. This is an extremely dangerous practice of putting untrained staff in threatening situations. The practice also diverts resources from other critical prison programs, the release said. 

At the conclusion of their evaluation, the OIG made 12 recommendations to the BOP to “address persistent operational deficiencies and improve its ability to mitigate risks that contribute to deaths of inmates in its custody.” 

In their response, BOP concurred with the recommendations and stated various corrections or enhancements would be made. The OIG gave them a deadline of May 15, to provide any evidence or documentation that action is being taken. 

Additional data on inmate deaths was published with the report. 

Of the 344 deaths in the eight-year period, 159 were suicide by hanging, 70 were the result of a drug overdose, 43 were from blunt-force trauma, 29 from stabbings and 20 from strangulation. The remaining 23 were classified as lacerations, asphyxia, other or unknown. 

The majority of inmate deaths were male (332) and white (242).  The OIG reviewed 83 sex offender deaths of which 56 were suicide, 17 were homicide, nine categorized as accidents, with one unknown. 

The 12 recommendations made by the OIG to the BOP: 

1. Develop strategies to ensure that staff assign accurate, consistent and timely Mental Health Care Level designations to inmates.  

2. Ensure that all institutions conduct required mock suicide drills and develop strategies to increase staff participation in those drills.  

3. 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.  

4. 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 74 staff should be issued and required to keep their own cut-down tool on their duty belt during their entire shift.

5. Ensure that each institution has a sufficient number of maneuverable gurneys in strategic locations to provide proper medical response during inmate transport.  

6. Issue standard, enterprise-wide guidance and training to staff on using the radio to communicate clear, descriptive information during inmate medical emergencies.  

7. 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.  

8. Ensure that all Evidence Recovery Teams are properly trained on post-incident evidence recovery protocols.  

9. Develop procedures to ensure that all required death-related records are completed and collected consistently and in accordance with established deadlines.  

10. 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.  

11. 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.  

12. 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.

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