Suicide is a leading cause of inmate death in both settings. According to the US Justice Department’s Bureau of Justice Statistics, there are over 300 county jail suicides each year. That makes suicide the leading cause of death in jails. If you work in a jail or prison, preventing suicide is a primary way to decrease patient injury and death.

While suicide deaths in the US population are just under 13 for every 100,000 citizens, suicide deaths in jails in 2013 were an astounding 46 per 100,000 inmates. The suicide rate in US jails is over 3.5 times the rate among the general public.

Lindsay Hayes MS, a Project Director with the National Center on Institutions & Alternatives in Mansfield, MA has followed jail suicide rates for over 35 years and he has seen significant progress in preventing suicides in our setting. He remembers at the start of his career that “the jail suicide rate was 107 suicides per 100,000 inmates or nine times greater than the general population. We have certainly come a long way since the 1980s, but have much more work to do.” He suggests the following interventions to keep your patients safe from harm by their own hand while in custody.

Start with Screening

Intake is the place where it all starts. There should be an evaluation of suicide potential for each patient that enters the correctional system. Although there are no intake screening forms that have been validated within the correctional environment, there is general agreement among experts that an effective suicide screening includes these eight areas.

• Past suicidal ideation and/or attempts
• Current ideation, threat, plan
• Prior mental health treatment/hospitalization
• Recent significant loss (job, relationship, death of family member/close friend, etc.)
• Sense of immediate future (inmate expressing helplessness and/or hopelessness)
• History of suicidal behavior by family member/close friend
• Verification of suicide risk during prior confinement
• Arresting/ transporting officer(s) or family member belief that the inmate is currently at risk

Of critical importance is the implementation of reasonable privacy and confidentiality during the intake process. Inmates will simply not respond truthfully to sensitive questions if they are asked in an open environment where reasonable privacy is not available.

Intake screening is a very effective way to identify potentially suicidal behavior. Because inmates can become suicidal at any point during their confinement, intake screening will only identify behavior that is self-reported, or provided by others such as law enforcement or family members.

Screening is Only the Beginning

While suicide screening at intake has significantly reduced deaths during the first 24 hours of confinement, suicides are now more likely to be evenly distributed during confinement. According to the most recent national study of jail suicides, 23% occurred within first 24 hours, 27% occurred between 2 and 14 days, and 20% between 1 and 4 months. This data suggests that there is need to target other high-risk periods, including when placed in segregation and upon return from court hearings that resulted in bad news. The challenge, of course, is to develop a system that is alert to these sensitive points in the incarceration timeline. One way is to train staff to be more attentive to the behavior of inmates returning from visits or after telephone calls.

Making the Most of a Bad Outcome

Even with a prevention plan in operation, a suicide can take place. It is a devastating situation for the inmate, family, and correctional staff. A thorough mortality review can help evaluate if the current suicide prevention program can be improved. This review should focus on organizational culture, system changes, and staff knowledge rather than seek to lay blame on any one person or department.

Here is a summary of the recommended process for a morbidity and mortality review as discussed by Lindsay Hayes, MS when he spoke at a recent NCCHC conference.

• First, every completed suicide, as well as serious suicide attempt (i.e., requiring medical treatment and/or hospitalization outside the facility), should be examined through a multidisciplinary morbidity-mortality review process that includes representation from correctional, mental health, and medical divisions. Exclusion of one or more disciplines will severely jeopardize the integrity of the review.
• Second, the primary purpose of the review is two-fold: “What happened in the case under review?” and “What can be learned to reduce the likelihood of future incidents?”
• Third, the review, separate and apart from other formal investigations that may be required to determine the cause of death, should include a critical inquiry of:
  • The circumstances surrounding the incident
  • Facility procedures relevant to the incident
  • All relevant training received by involved staff
  • Pertinent medical and mental health services/reports involving the decedent
  • Possible precipitating factors (i.e., circumstances which may have caused the suicide or serious suicide attempt)
  • Recommendations, if any, for changes in policy, training, physical plant, medical or mental health services, and operational procedures

Suicide is a potential patient safety issue throughout the incarceration period. By being ever mindful of this possibility, we may have opportunity to prevent patient self-injury and death. Organizational culture and systems can support these efforts.

How do you prevent suicide in your setting? Share your experience in the comments section of this post.