REPORT ON SUICIDE PREVENTION PRACTICES WITHIN THE HARRIS COUNTY JAIL SYSTEM Houston, Texas lax. Lindsay M. Hayes 40 Lantern Lane 0 Mans?eld, MA 02048 (508) 337-8806 email: Lhayesta@msn.com for 0 Jun Leltner, General Counsel Harris County Sherist Of?ce June 8, 2014 C. D. 1? 51M TABLE OF CONTENTS Findings and 1) Staff 2) 3) 4) 5) Levels of 6) 7) 8) Follow-up/Mortality Appendix WORK PRODUCT: EXPERT REPORT ON SUICIDE PREVENTION REPORT ON SUICIDE PREVENTION PRACTICES WITHIN THE HARRIS COUNTY JAIL SYSTEM Houston, Texas A. INTRODUCTION The following is a summary of the observations, ?ndings, and recommendations of Lindsay M. Hayes following the provision of short-term suicide prevention technical assistance to the Harris County Sheriff" 5 Of?ce (HCSO) in Houston, Texas. As of April 2014, the HCSO had experienced a higher number (three) of inmate suicides than in previous years. Because of the higher incidence of suicide, the HCSO and its mental health provider (Mental Health/Mental Retardation Authority of Harris County) began to examine the deaths, as well as review various policy and procedural directives relating to suicide prevention. In order to independently assess current practices, as well as offer any appropriate recommendations to suicide prevention policies and procedures within the HCSO, Sheriff Adrian Garcia and Jim Leitner, HCSO General Counsel, decided to seek the assistance of an outside consultant. It should be noted that the determination for the need of this writer?s assessment was not prompted by litigation or critical investigation of any of the recent inmate suicides. Rather, these actions were taken through the pro-active initiative of Sheriff Garcia who was committed to determining what steps, if any, were necessary to improve jail suicide prevention practices within the Harris County Sheriff?s Of?ce. In conducting the assessment, this writer met with and/or interviewed numerous correctional, medical, and mental health of?cials and staff from HCSO and Mental Health/Mental Retardation Authority (MHMRA) of Harris County; reviewed numerous policies WORK PRODUCT: EXPERT REPORT ON SUICIDE PREVENTION and procedures related to suicide prevention, screening/assessment protocols, and training materials; reviewed various health care chats and investigative reviews of seven (7) inmate suicides between March 2012 and April 2014;1 and toured the four (4) facilities that comprise the Harris County Jail System. These jail facilities are in close proximity to each other at 1200 Baker Street and 1307 Baker Street, 701/711 North San Jacinto, and 1201 Commerce Street (Inmate Processing Center) The on?site assessment was conducted on May 13 thru May 16, 2014. As of April 2014, the Harris County Jail System had an average daily population of 8,604 inmates, with more than 120,000 inmates processed through the facility each year, making it one of the largest jail systems in the United States. As shown by Table 1, the HCSO has experienced 9 inmate suicides during the 6-year period of 2009 through 2014, including three (3) deaths this year. Based upon the average daily population during this same time period, the suicide rate in the HCSO was deaths per 100,000 inmates a rate that is substantially below that of hag?=5 county jails of varying size throughout the United States.2 lThe investigative review of the most recent inmate suicide occurring in April 2014 had not yet been completed at the time of this writer?s assessment and, therefore, not available for review prior to development of this report. 2 According to Heron, M. (2012), ?Deaths: Leading Cause for 2009," National Vital Smtislics Report, 61 (7), Hyattsville, MD: National Center for Health Statistics, the suicide rate in the general population is approximately deaths per 100,000 citizens. According to the most re?Cent data anail suicide, the suicide rate in county jails throughout the country is approximat ?1 per 100,000 inmates, Noon n, M. and Ginder, S. (2013), Mortality in Local Jails and Stale Prisons, DC: Bureau of Justice Statistics, US Department of Justice, Office of Justice Programs. WORK PRODUCT: REPORT ON SUICIDE PREVENTION TABLE 1 AVERAGE DAILY POPULATION, SUICIDES, AND SUICIDE RATE WITHIN THE HARRIS COUNTY JAIL SYSTEM JANUARY 2009 THRU APRIL 2014* Y_ezg Suicide Rate 2009 11,214 0 0 2010 10,310 2 19.4 2011 9,659 0 0 2012 8,880 23 22.5 2013 9,087 2 22.0 2014 8,604 3 34.9 2009-2014 57,774 9 15.6 *Source: Harris County Sheriff?s Of?ce 30110 of the suicides occurred in a HCSO substation holding 060, and not in any of the main jail facilities. WORK PRODUCT: EXPERT REPORT ON SUICIDE PREVENTION B. FINDINGS AND RECOMMENDATIONS Detailed below is this writer?s assessment of jail suicide prevention practices within the Harris County Sheriff?s Of?ce. It is formatted according to this writer?s eight (8) critical components of a suicide prevention policy: staff training, identi?cation/screening, communication, housing, levels of supervision/management, intervention, reporting, and follow up/morbidity?mortality review. This protocol was previously developed by this writer and is consistent with national correctional standards, including those of the American Correctional Association?s Performance-Based Standards for Adult Local Detention Facilities (2004); Standard J-G-OS of the National Commission on Correctional Health Care?s Standards for Health Services in Jails (2008);4 and the ?Suicide Prevention and Intervention Standard? of the US. Department of Homeland Security?s Operations Manual ICE Performance-Based National Detention Standards as well as the Texas Administrative Code (Title 37, Chapter 273.5: Mental Disabilities/Suicide Prevention Plan).6 Where indicated, are also provided. Finally, this writer reviewed various Harris County suicide prevention policies, including the ?Suicide Prevention Program? (No. .G.05) and ?Suicide Prevention Plan (No. CJC- 235), as well as ?Monitoring Suicidal Patients.? 4It should be noted that the Harris County Sheriff?s Of?ce has been accredited by the National Commission on Correctional Health Care for many years. sAmerican Correctional Association (2004), Peiformance-Based Standards forAdult Local Detention Facilities, 40? Edition, Lanham, MD: Author; National Commission on Correctional Health Care (2008), Standards for Health Services in Jails, 8th Edition, Chicago, IL: Author; and US. Department of Homeland Security (2011), Immigration and Customs Enforcement, Operations Manual ICE Performance-Based National Detention Standards, Washington, DC: Author. 6Texas Administrative Code, Title 37, Chapter 273: Mental Disabilities/Suicide Prevention Plan. WORK PRODUCT: EXPERT REPORT ON SUICIDE PREVENTION 1) Staff Training All correctional, medical, and mental health staff should receive eight (8) hours of initial suicide prevention training, followed by two (2) hours of annual training. At a minimum,? training should include avoiding negative attitudes to suicide: prevention, inmate suicide research, why correctional environments are conducive to suicidal behavior, potential 53 predisposing factors to suicide, high-risk suicide periods, a, warning signs and identifying suicidal inmates despite the denial of risk, components of the agency?s suicide g? prevention policy, and liability issues associated with inmate suicide. The key to any suicide prevention program is properly trained correctional staff, who form the backbone of any correctional system. Very few suicides are actually prevented by mental health, medical or other professional staff. Because inmates attempt suicide in their housing units, often during late afternoon or evening, as well as on weekends, they are generally outside the purview of program staff. Therefore, these incidents must be thwarted by correctional staff who have been trained in suicide prevention and are able to demonstrate an intuitive sense regarding the inmates under their care. Simply stated, correctional officers are often the only staff available 24 hours a day; thus they form the front line of defense in suicide prevention. Both the American Correctional Association (ACA) and National Commission on Correctional Health Care standards stress the importance of training as a critical component to any suicide prevention program. ACA Standard 4-ALDF-7B-10 requires that all correctional staff receive both initial and annual training in the ?signs of suicide risk? and ?suicide precautions,? while Standard requires that staff be trained in the implementation of the suicide prevention program. As stressed in Standard -- WORK PRODUCT: EXPERT REPORT ON SUICIDE PREVENTION ?All staff members who work with inmates are trained to recognize verbal and behavioral cues that indicate potential suicide, and how to respond appropriately. Initial and at least biennial training are provided, although annual training is highly recommended.? Finally, the US. Department of Homeland Security?s Operations Manual ICE Performance-Based National Detention Standards require that all staff receive both pre?service and annual training in the following areas: recognizing verbal and behavioral cues that indicate potential suicide; demographic, cultural, and precipitating factors of suicidal behavior; responding to suicidal and depressed detainees; effective communication between correctional and health care personnel; necessary referral procedures; constant observation and suicide-watch procedures; follow-up monitoring of detainees who have already attempted suicide; and reporting and written documentation procedures.? FINDINGS: According to the ?Suicide Prevention Program? (No. J.G.05), ?appropriate persons assigned to the Classi?cation Section, Booking and Release Section, and Health Services shall receive a minimum of two hours training annually.? It was unclear from this language if all custody staff, including detention of?cers, were required to go through such training. (Although custody data reviewed by this writer indicated a requirement that all custody personnel were required to be trained). There was and is an assortment of suicide prevention training offered to custody, medical, and mental health personnel within the Harris County Jail System. For example: WORK PRODUCT: REPORT ON SUICIDE PREVENTION Custody: - There was a 8-hour ?Suicide Detection and Prevention in Jails: Course No. 3501? classroom?instructed training originally developed by the Texas Commission on Law Enforcement Of?cer Standards and Education (TCLEOSE). This training workshop is very comprehensive] however, is not mandatory, and only required for those of?cers desiring a higher level of TCLEOSE certi?cation; A 1?hour ?Classification and Suicide Screening? on?line course, available through the Texas Engineering Extension Service, was required for all new HCSO employees during the orientation process; 0 A 16?hour ?Crisis Intervention Training? workshop, that included instruction on suicide prevention, has been required for all new of?cers since 2011; and A l~hour ?Suicide Screening and Prevention? on-Iine course comprised of 28 PowerPoint slides was required for all HCSO jail personnel on both a pre-service and annual basis. The slides covered various topics, including and facts regarding suicide, situational and personal factors of jail suicides, signs and of potential suicidal behavior, warning signs and role of the of?cer in suicide prevention, risk levels of suicidal inmates, supervising suicidal inmates, and responding to a suicide attempt. Medical and Mental Health: 0 All medical and mental health staff were required to read a 7-page article entitled ?The Role of Corrections Professionals in Preventing Suicide,? as well as a 19- page ?Suicide/Homicide: Prevention and Precautions, Screening and Consumer Crisis Procedures, Annual Update Self-Study Packet.? The materials, apparently available online, were required to be read on both a pre-service and annual basis. Although the 7?page article was related to inmate suicide prevention, only 8 pages of the 19-page packet contained information on suicide prevention and it was limited to and facts and demographic characteristics of suicide victims in the community. According to training data reviewed by this writer, approximately 67% of custody staff, and 100% of both medical and mental health personnel, completed the on-line annual suicide prevention training requirements during 2013.8 7Of note, this curriculum was originally developed by TCLEOSE based upon this writer?s Training Curriculum on Suicide Detection and Prevention in Jails and Lockups, 1988. 8The percentage for custody staff excludes new employees. WORK PRODUCT: EXPERT REPORT ON SUICIDE PREVENTION 10 In conclusion, it would be this writer?s opinion that, although the Harris County Jail System may very well be compliant with the training requirements of both the Texas Commission on Jail Standards and National Commission on Correctional Health Care, the number of hours and overall content of the required annual suicide prevention training for correctional, medical, and mental health staff was inadequate. In particular, the 19-page ?Suicide/Homicide: Prevention and Precautions, Screening and Consumer Crisis Procedures, Annual Update Self-Study Packet,? with no reference to suicide prevention in jails, was generally unhelpful for the instruction to medical and mental health personnel. Finally, it has been this writer?s experience (and inherent bias) that online training, although convenient for administrators and personnel, is generally not as effective as live, classroom instruction that allows for both collaboration and participation of correctional, medical, and mental health staff. RECOMMENDATIONS: Several recommendations are offered to strengthen both the length and content of jail suicide prevention training offered to both correctional and healthcare personnel who work within the Harris County Jail System. irsf, it is strongly recommended that the HCSO require that all new employees complete the 8?hour ?Suicide Detection and Prevention in Jails: Course No. 3501? classroom-instructed training developed by TCLEOSE. Second, suicide prevention is all about pro-active attitudes and collaboration, principles that are lost sitting alone in a chair at a computer terminal. As such, it is strongly recommended the HCSO and MHMRA require annual suicide prevention training and that both agencies collaborate on a 2-hour curriculum that includes the following topics: WORK PRODUCT: EXPERT REPORT ON SUICIDE PREVENTION i 11 avoiding obstacles (negative attitudes) to prevention inmate suicide research why facility environments are conducive to suicidal behavior identifying suicide risk despite the denial of risk potential predisposing factors to suicide high?risk suicide periods warning signs and components of the suicide prevention program 0 I There are several nationally-recognized suicide prevention training curricula, including the above referenced TCLEOSE curriculum (?Suicide Detection and Prevention in Jails: Course No. 3501?), that can be utilized as guides to development of the recommended suicide prevention training curriculum.9 Much of this information is available through the US Justice Department?s National Institute of Corrections at the following website: In addition, the new curriculum should include recent national data on inmate suicides. Data from this writer?s National Study of Jail Suicide: 20 Years Later can be included in the curriculum.10 9See, for example, Hayes, L.M. and Rowan, .R. (1995), Training Curriculum on Suicide Detection and Prevention in Jails and Lock-ups, Mans?eld, MA: National Center on Institutions and Alternatives; New York State, Of?ce of Mental Health, Commission of Correction (2003), Suicide Prevention and Crisis Intervention in County Jails and Police Lockaps Basic Program Trainer?s Manual, Albany, NY: Authors. 10Hayes, L.M (2010), National Study of Jail Suicides: 20 Years Later, Washington, DC: National Institute of Corrections, US Department of Justice, custody/publicationsl; Hayes, L. (2012), ?National Study of Jail Suicides: 20 Years Later,? Journal of Correctional Health Care, 18 (3). WORK PRODUCT: EXPERT REPORT ON SUICIDE PREVENTION 12 2) Intake Screening/Assessment Intake screening for suicide risk must take place immediately upon confinement and prior to housing assignment. This process may be contained within the medical screening form or as a separate form, and must include inquiry regarding: past suicidal ideation and/or attempts; current ideation, threat, plan; prior mental health treatmcut/hospitalization; recent significant loss (job, relationship, death of family member/ close friend, etc); history of suicidal behavior by family member/close friend; suicide risk during prior con?nement; transporting officer(s) believes inmate is currently at risk. The intake screening process should include procedures for referral to mental health and/or medical personnel. Any inmate assigned to a special housing unit should receive a written assessment for suicide risk by mental health staff upon admission. Intake screening/assessment is also critical to a correctional system?s suicide prevention efforts. An inmate can attempt suicide at any point during incarceration beginning immediately following reception and continuing through a stressful aspect of con?nement. Although there is disagreement within the and medical communities as to which . factors are most predictive of suicide in general, research in the area of jail and prison suicides intoxication, emotional state, family history of suicide, recent signi?cant loss, incarceration,_iack of social supp01t system, histmy, and various ?stressors of ?11 Most importantly, prior research has consistently reported that at least two con?nement. thirds of all suicide victims communicate their intent some time prior to death, and that any individual with a history of one or more suicide attempts is at a much greater risk for suicide than ?Bonner, R. (1992), ?Isolation, Seclusion, and Vulnerability as Risk Factors for Suicide Behind Bars,? in R. Maris et. a1. (Editors) Assessment and Prediction of Suicide, New York, NY: Guilford Press, 398-419. WORK PRODUCT: EXPERT REPORT ON SUICIDE PREVENTION has identi?ed a number of characteristics that are to suicide, including: limited prior a 13 those who have never made an attempt.12 In addition, according to the most recent research on inmate suicide, at least one-third of all inmate suicide victims had prior histories of both mental illness and suicidal behavior.13 The key to identifying potentially suicidal behavior in inmates is through inquiry during both the intake screening/assessment phase, as well as other high-risk periods of incarceration. Finally, given the strong association between inmate suicide and special management disciplinary and/or administrative segregation) housing unit placement, any inmate assigned to such a special housing unit should receive a written assessment for suicide risk by mental health staff upon admission to such placement. Both the ACA and standards address the issue of assessing inmates assigned to segregation. According to ACA Standard 4-ALDF-2A-45: ?When an inmate is transferred to segregation, health care personnel are informed immediately and provide assessment and review as indicated by the protocol as established by the health authority.? Standard .T-E-09 states that ?Upon noti?cation that an inmate is placed in segregation, a quali?ed health care professional reviews the inmate?s health record to determine whether existing medical, dental, or mental health needs contraindicate the placement or require accommodation.? FINDINGS: The HCSO suicide prevention policies adequately address requirements for intake screening to identify potentially suicidal behavior. Upon admission, all new inmates are processed through the Inmate Processing Center (IPC). A booking officer completes a screening 12Clark, D. and S.L. Horton-Deutsch (1992), ?Assessment in Absentia: The Value of the Autopsy Method for Studying Antecedents of Suicide and Predicting Future Suicides," in R. Maris et. al. (Editors) Assessment and Prediction of Suicide, New York, NY: Guilford Press, 144~182. l3Hayes, LM. (2010), National Study of Jail Suicide: 20 Years Later, Washington, DC: U.S. Department of Justice, National Institute of Corrections; ?National Study of Jail Suicides: 20 Years Later,? Journal of Correctional Health Care, 13 WORK PRODUCT: EXPERT REPORT ON SUICIDE PREVENTION 14 form entitled ?Screening Form for Suicide and Medical and Mental Impairments? on each newly admitted inmate. The form, which is mandated by the Texas Commission on Jail Standards, includes inquiry regarding arresting officer observations, depression, current and prior suicidal behavior, and staff observation of unusual behavior. This writer had an opportunity to review this intake screening process during the on-site assessment. The form is embedded in the jail management program and, although the process is compromised by the lack of privacy afforded I the inmate during completion of the screening, this writer observed that all questions were asked as required. One concern regarding this screening form is that, HCSO health care staff informed this writer that they do not receive copies of an inmate?s completed ?Screening Form for Suicide and Medical and Mental Impairments.? Custody personnel stated that although hard copies of the form are not forwarded to medical staff, form is scanned into, and available from, the HCSO jail management program. There was con?icting information as to whether or not HCSO health care staff had access to the program. All inmates were also required to receive ?Intake Health Screening? by nursing staff assigned to the IPC. The form, embedded into the EMR (from GE Centricity), contained limited inquiry regarding mental health and suicidal behavior, including hist01y of mental illness, state of consciousness, signs of mental disorder, current suicidal ideation, and prior suicide attempts. This writer had an opportunity to observe the intake screening process performed by nursing staff on May 14, 2014. Two nurses were sitting side-by-side at a counter, separated by a small divider. On the other side of the counter separated by glass partition, was a small staging WORK PRODUCT: EXPERT REPORT ON SUICIDE PREVENTION 15 area with two chairs close to the counter. The chairs were separated by a small divider. This writer observed approximately 22 inmates escorted from an adjacent holding cell and instructed to enter the staging area and stand behind a yellow line. Two inmates at a time were then instructed to step up and sit in the chairs to begin the intake screening process. The distance between the yellow line and the chairs was approximately 5 feet. In addition to asking questions contained on the intake screening form, the nurses were required to take each inmate?s temperature and blood pressure. This writer observed that the intake screening of the 22 inmates was performed in less than 30 minutes by the two nurses, and each screening (including temperature and blood pressure) took between 1 and 3 minutes. The intake screening process was problematic for several reasons. First, there was no privacy afforded to any inmate. Not only could the two inmates being screened hear each other, but the process could be easily overheard by the multiple inmates standing less than 5 feet away. More importantly, although the ?Intake Health Screening? form contained 11 areas of physical health and mental health inquiry, with multiple subcategories of questions, the nurses were observed not to be asking all of the required questions. In fact, one nurse never asked any inmate Maw-f- whether they were currently experiencing suicidal ideation and/or had a prior history of suicidal behavior. Due to the obvious problems observed during the intake screening process, this writer conferred with both the Executive Director of Health Services Detention Bureau and the Jail Mental Health Administrator for Harris County. The following day (May 15), the Health Services Detention Bureau Executive Director informed this writer of several changes WORK PRODUCT: EXPERT REPORT ON SUICIDE PREVENTION 16 to the intake screening process at the IPC. First, beginning immediately, all newly arrived inmates awaiting intake screening would continue to be held in a large holding cell until it was time for their individual screening. Then, only two inmates at a time would be brought into the small staging area for the screening process. Second, all nursing staff had been informed that it would be a violation of HCSO policy if all areas of inquiry contained on the intake health screening form were not completed as required. Third, the EMR was revised to ensure that users of the screening form could not skip areas of inquiry, each question must be answered before the user was allowed to move on to the next question. The promptness of the above corrective action by the Executive Director of Health Services Detention Bureau was very commendable. (A recommendation for adding additional questions related to suicide risk inquiry during the intake screening process will be offered below.) In addition, one of the indicators of current suicide risk during con?nement is suicide risk during prior con?nement, as well as prior history of mental illness. In this writer?s case ?le review of the seven (7) inmates who recently committed suicide within the Harris County Jail System between 2012 and 2014, at least two cases involved an inmate who have attempted suicide during a recent prior con?nement, while another involved an inmate who, although denying a history of mental illness at intake, had a ?caution screen? alert in the HCSO jail management system for a prior history of mental illness and recent discharge from a hospital. Although the Centricity EMR has the ability to capture information about an imnate?s placement on suicide precautions during a prior HCSO con?nement, as well as other pertinent mental health information, this feature was currently not being utilized. (The Executive Director WORK PRODUCT: EXPERT REPORT ON SUICIDE PREVENTION 17 of Health Services Detention Bureau informed this writer that the feature will be activated during the next EMR upgrade.) Further, following the intake screening process by nursing staff, all newly admitted inmates were seen by HCSO classi?cation staff who administer an ?Inmate Needs Assessment or Reassessment Form.? The form provided adequate inquiry regarding mental health and suicide risk history. In addition, classification staff run a CCQ (Continuity of Care Query) check to determine if the inmate had previously received mental health services from a state agency. This was an excellent practice. Finally, in addition to a ?Health Assessment? form that was completed by medical staff within 14 days of the inmate?s con?nement that provided adequate inquiry regarding mental health and suicide risk, this writer was informed that nursing staff were required to make daily rounds of segregation, whereas a mental health clinician conducted rounds once or twice a week in segregation. These were good practices. In sum, the HCSO had multiple layers of intake screening to identify both imnates with 1f?? mental illness and potentially suicidal behavior. However, the intake screening process conducted by nursing staff was observed to be very problematic (although sustainable corrective action was hopefully put in place while this writer was on-site), suicide risk inquiry was not as 4 - 4? a robust as it could be, and an alert system should be activated within the Centricity EMR. WORK PRODUCT: EXPERT REPORT ON SUICIDE PREVENTION 18 RECOMMENDATIONS: A few recommendations are offered to improve the intake screening/assessment process within the Harris County Sherist Of?ce. First, it is strongly recommended that the current suicide risk inquiry contained on the current ?Intake Health Screening? in the Centricity EMR be enlarged to include the following: - Have you ever attempted suicide? 0 Have you ever considered suicide? 0 Are you now or have you ever been treated for mental health or emotional problems? 0 Have you recently experienced a signi?cant loss (relationship, death of family member/close friend, job, etc)? 0 Has a family member/close friend ever attempted or committed suicide? 0 Do you feel there is nothing to look forward to in the immediate future (inmate expressing helplessness and/or hopelessness)? Are you thinking of hurting and/or killing yourself? Second, it is strongly recommended that the HCSO Health Services Detention Bureau initiate a continuous quality assurance audit of the intake screening process to ensure that newly admitted inmates are receiving adequate privacy and that all intake questions are being asked by nursing staff as required. Third, regardless of the inmate?s behavior or answers given during intake screening, an immediate referral to mental health staff should always be initiated based on documentation re?ecting possible mental illness and/or suicidal behavior during an inmate?s prior confinement within the HCSO. As such, the ?alert screen? should be activated within the Centricity EMR according to the following procedures: 0 Any inmate placed on suicide precautions should be tagged on the ?alert screen? of the Centricity EMR by mental health staff; WORK PRODUCT: EXPERT REPORT ON SUICIDE PREVENTION 19 0 Nursing staff conducting intake screening should always review the inmate?s alert screen to verify whether they were previously con?ned in the HCSO and had any history of suicidal behavior/placement on suicide precautions during a prior con?nement; and Regardless of the inmate?s behavior or answers given during intake screening, an immediate referral to mental health staff should always be initiated based on documentation re?ecting possible mental illness and/or suicidal behavior during an inmate?s prior con?nement within the HCSO. Fourth, this writer was informed that the Pie?Trial Screening Division of the Harris County Pie-Trial Services Agency conducted an assessment of all newly arrived HCSO inmates to determine their eligibility for pre?trial diversion. Part of the assessment included inquiry regarding mental health and suicide risk. This writer reviewed the assessment form and found it to be potentially very useful. However, it would appear that there currently was no formal policy or procedure by which staff of the Pre-Trial Screening Division informed HCSO personnel that an inmate might be at risk for suicide. As such, it would be strongly recommended that HCSO and Harris County Pie-Trial Services of?cials collaborate on developing a formal mechanism of referral. 3) Communication Procedures that enhance communication at three levels: 1) between the sending of?cer(s) and correctional staff; 2) between and among staff (including medical and mental health personnel); and 3) between staff and the suicidal inmate. Certain signs exhibited by the inmate can often foretell a possible suicide and, if detected and communicated to others, can prevent such an incident. There are essentially three levels of communication in preventing inmate suicides: 1) between the sending institution/arresting- transporting officer and correctional staff; 2) between and among staff (including mental health WORK PRODUCT: EXPERT REPORT ON SUICIDE PREVENTION 20 and medical personnel); and 3) between staff and the suicidal inmate. Further, because inmates can become suicidal at any point in their incarceration, correctional staff must maintain awareness, share information and make appropriate referrals to mental health and medical staff. FINDINGS: Effective communication between correctional, medical, and mental health staff is not an issue that can be easily written as a policy directive, and is often dealt with more effectively through examples of multidisciplinary problem-solving. Although on-site for only a few days, this writer sensed that correctional, medical, and mental health personnel had a good working relationship. In addition, the Centricity EMR is now fully integrated and contains both medical and mental health records that better ensures the continuity of care and enhancing communication.l4 Further, there are regularly scheduled management meetings between HCSO custody and medical staff, as well as MHMRA supervisory personnel. As explained in more detail later in this report, a Suicide Prevention Committee was established in January 2014 and meets at a minimum quarterly basis. A ?Referral for Screening Form? can be completed by any staff to refer an inmate to MHMRA personnel on either a routine or emergent basis. Finally, a Crisis Intervention Response Team (CIRT), comprised of a specially-trained group of certified deputies and detention officers, are deployed as first responders to mental health emergencies and make referrals to MHMRA as appropriate. These are all good practices. However, as explained in greater detail on pages 25-31, this writer has several concerns regarding the CIRT process when responding to potentially suicidal inmates. RECOMMENDATIONS: None l"This writer was informed that the EMR was initially activated in December 2012, with the mental health section activated in November 2013. WORK PRODUCT: EXPERT REPORT ON SUICIDE PREVENTION 21 4) Housing r'Isolation should be avoided. Whenever possible, house in general population, mental health unit, or medical infirniary, located in close proximity to staff. Inmates should be housed .r in suicide?resistant, protrusion-free cells. Removal of an inmate?s clothing (excluding belts and Shoelaces), as well as use of physical restraints restraint chairs/boards, straitjackets, leather straps, etc.) and cancellation of routine ., privileges (showers, visits, telephone calls, recreation, etc.), should be avoided whenever possible, and only utilized as a last i resort for periods in which the inmate is physically engaging in self-:destructive behavior. In determining the most appropriate location to house a suicidal inmate, there is often the tendency for correctional of?cials in general to physically isolate the individual. This response may be more convenient for staff, but it is detrimental to the inmate. The use of isolation not only escalates the inmate?s sense of alienation, but also further serves to remove the individual from proper staff supervision. National correctional standards stress that, to every extent possible, suicidal inmates should be housed in the general population, mental health unit, or medical infirmary, located in close proximity to staff. Of course, housing a suicidal inmate in a general population unit when their security level prohibits such assignment raises a dif?cult issue. The result, of course, will be the asSignment of the suicidal inmate to a housing unit commensurate with their security level. Within a correctional system, this assignment might be a ?special housing? unit, restrictive housing, disciplinary confinement, administrative segregation, etc., However, to every extent possible, such inmates should be housed in suicide-resiStant, protrusion-free cells. Further, cancellation of routine privileges (showers, visits, telephone calls, recreation, etc.), removal of clothing (excluding belts and Shoelaces), as well as the use of physical restraints restraint WORK PRODUCT: EXPERT REPORT ON SUICIDE PREVENTION 22 chairs/boards, straitjackets, leather straps, etc.) should be avoided whenever possible, and only utilized as a last resort for periods in which the inmate is physically engaging in self-destructive behavior. Housing assignments should not be based on decisions that heighten depersonalizing aspects of incarceration, but on the ability to maximize staff interaction with inmates. FINDINGS: Pursuant to HCSO and MHMRA suicide prevention policies, inmates identi?ed as suicidal were generally housed in any of the four (4) acute mental health units (2C1, 2C2, 2P1, or 2P2) or in the separation (segregation) units (21, 2K, 2L, and 2M in the Baker Street facility as well as separation units in the North San acinto Street facility). 2C1 had six (6) single cells and 56 dormitory beds, 2C2 had one (1) single cell and 24 dormitory beds, 2P1 had four (4) single female cells and 16 single male cells, and 2P2 had all single cells. 2C1 and 2P2 housed all-male patients; whereas 202 and 2P1 housed both male and female patients. In addition, the medical infirmary unit could be utilized for over?ow suicide precautions, although it was said to I [it"nli?l {i ll ?Ah? 4,1 i be rarely utilized for that purpose. 4i". 1U This writer examined each of the single cell loCations and found that they were not ?suicide-resistant? because they contained various protrusions that could act as an anchoring device from which an inmate could attach a ligature in a suicide attempt by hanging. For example, potentially dangerous anchoring devices included ventilation holes in bunks, desk/stool brackets, smoke detector cages, exposed sprinkler heads/piping and some sprinkler head covers not ?ush with ceilings, and possible gaps between light ?xtures and ceilings.? 15Although none of the inmates who recently committed suicide in the Harris County Jail System were on suicide precautions at the time of their deaths, common anchoring devices in the suicides included smoke detector cages and sprinkler heads. WORK PRODUCT: EXPERT REPORT ON SUICIDE PREVENTION 23 RECOMMENDATIONS: The following recommendations are offered to improve the housing of inmates on suicide precautions within the Harris County Jail System. First, it is strongly recommended that HCSO of?cials embark upon an inspection program to ensure that inmates on suicide precautions are housed in ?suicide?resistant? cells, without any obvious protrusions that would easily enable an inmate to hang themselves. For example, bunk holes should be covered and/or bunk replaced, dangerous ventilation grates be replaced with grates that have holes that are ideally 1/8 inches in diameter and no more than 3/16 inches diameter (or 16- mesh per square inch), and smoke detector and sprinkler head covers should be ?ush with the ceiling, and gaps between light ?xtures and ceilings should be covered with security caulking. Speci?c recommendations regarding the removal of obvious protrusions in cells can be found in the ?Checklist for the ?Suicide-Resistant? Design of Correctional Facilities,? which is contained in Appendix A of this report. Second, current HCSO and MHMRA suicide prevention policies do not address procedures for deciding which possessions and privileges are provided to inmates on suicide precautions. As such, it is strongly recommended that the policies be revised to include the following requirements: 0 All decisions regarding the removal of an inmate?s clothing, bedding, possessions-l (books, slippers/sandals, eyeglasses, etc.) and privileges shall be commensurate with the level of suicide risk as determined on a case-by-case basis by mental health staff; 0 If mental health staff determine that an inmate?s clothing needs to be removed for reasons of safety, the inmate shall always be issued a safety smock and safety blanket;l6 16This writer observed at least one inmate on suicide precautions that was clothed only in a paper gown. Paper gowns should no! be utilized in the Harris County Jail System. Their use is antiquated and generally dehumanizing. Only a safety smock made of heavy fabric should be utilized. WORK PRODUCT: EXPERT REPORT ON SUICIDE PREVENTION 24 A mattress shall be issued to all inmates on suicide precautions unless the inmate utilizes the mattress in ways in which it was not intended attempting to tamper with/destroy, utilizes to obstruct visibility into the cell, etc.); All inmates on suicide precautions shall be allowed all routine privileges family visits, telephone calls, recreation, etc.), unless the inmate has lost those privileges as a result of a disciplinary sanction; and Inmates on suicide precautions shall not automatically be locked down. They should be allowed dayroom access commensurate with their security level and clinical judgment of mental health staff. 5) Levels of Sunervision/Management Two levels of supervision are generally recommended for suicidal inmates -- close observation and constant observation. Close Observation is reserved for the inmate who is not actively suicidal, but expresses suicidal ideation and/or has a recent prior history of self-destructive behavior. In addition, an inmate who denies suicidal ideation or does not threaten suicide, but demonstrates other concerning behavior (through actions, current circumstances, or recent history) indicating the potential for self-injury, should be placed under close observation. This inmate should be observed by staff at staggered intervals not to exceed every 10 minutes. Constant Observation is reserved for the inmate who is actively suicidal, either by threatening or engaging in self-injury. This inmate should be observed by a staff member on a continuous, uninterrupted ,basis. Other supervision aids closed circuit television, inmate companions/watchers, etc.) can be utilized as a supplement to, but never as a substitute for, these observation levels. Inmates on suicide precautions should be reassessed on a daily basis. Experience has shown that prompt, effective emergency medical service can save lives. Research indicates that the overwhelming majority of suicide attempts in custody is by hanging.17 Medical experts warn that brain damage from can occur within four minutes, with death often resulting within five to six minutes. In inmate suicide attempts, the 1"Hayes, LM. (2010), National Study of Jail Suicide: 20 Years Later, Washington, DC: US. Department of Justice, National Institute of Corrections; ?National Study of Jail Suicides: 20 Years Later,? Journal of Correctional Health Care, 18 (3). WORK PRODUCT: EXPERT REPORT ON SUICIDE PREVENTION 25 promptness of the response is often driven by the level of supervision afforded the inmate. Both the ACA and standards address levels of supervision, although the degree of speci?city varies. ACA Standard vaguely requires that ?suicidal imnates are under continuous observation,? while Standard requires physical observation ranging from ?constant supervision? to ?every 15 minutes or more frequently if necessary.? According to the Suicide Prevention and Intervention Standard from the US. Department of Homeland Security?s Operations Manual ICE Performance-Based National Detention Standards, ?Suicidal detainees will be monitored by the assigned security of?cers who maintain constant one-on-one visual observation, 24 hours a day, until the detainee is released from suicide watch. The assigned security of?cer makes notations every 15 minutes on the behavioral observation checklist.? In addition, the component of ?Levels of Supervision? encompasses the overall management of the inmate on suicide precautions and includes the appropriate level of observation, timely and comprehensive suicide risk assessments, downgrading the level of observation following a period of stability, and providing periodic follow-up assessments following discharge from suicide precautions based upon an individualized treatment plan. FINDINGS: Both the HCSO and MHMRA provide limited narrative in their respective suicide prevention policies regarding levels of observation afforded to inmates on suicide precautions. It would appear that the current practice within the Harris County Jail System is for inmates identi?ed as suicidal to be placed on suicide precautions and observed at 15-minute intervals in either one of the four acute mental health units or in one of the separation (segregation units) at either the Baker Street or North San Jacinto Street facilities. There did not WORK PRODUCT: EXPERT REPORT ON SUICIDE PREVENTION 26 appear to be an option for continuous, uninterrupted constant observation for inmates at the highest level of suicide risk (although there was dormitory-style housing available in two of the acute mental health units that could provide continuous observation from technician staff situated in the dayrootn). Based upon the observations of this writer, as well as conversations with mental health staff and review of several medical charts, it appeared that when inmates were viewed as ?genuinely? suicidal and/0r actually attempted suicide they were more likely to be managed within one of the four acute mental health units; whereas imnates suspected of being manipulative or malingering in their suicidal threats and/or gestures were more likely to be managed within one of the separation units on suicide precautions.l8 Inmates housed in an acute mental health unit on suicide precautions would be assessed for continued suicide risk on a daily basis by a [Since February 2014, have been utilizing a ?Suicide Risk Assessment? (SRA) form that was embedded into the On the other hand, inmates housed in a separation unit cell on suicide precautions would be assessed for continued suicide risk by mental health staff; and often only during twice-weekly rounds of the separation unit not necessarily on a daily basis). These mental health staff were not required to utilize an SRA when assessing an inmate?s continued risk for suicide in a separation unit. The dichotomy in frequency of assessment and use of the SRA form by mental health staff when managing inmates considered genuinely suicidal as opposed to those perceived as manipulative was concerning. 18In fact, some working within the Harris County Jail System had coined the term ?Suicidal Gesture in a Setting of High Probability of Rescue? as an added diagnosis in their progress notes of inmates apparently viewed as manipulative. WORK PRODUCT: EXPERT REPORT ON SUICIDE PREVENTION 27 In addition and as brie?y discussed in a prior section of this report, a Crisis Intervention Response Team (CIRT), comprised of a specially-trained group of certi?ed deputies and detention of?cers, were deployed as ?rst responders to mental health emergencies and made referrals to MHMRA as appropriate. Inmates who threatened suicide in numerous housing units within the Harris County Jail System were often initially responded to by the CIRT. Review of the HCSO poiicy on CIRT, entitled ?Addressing Inmates with Mental Health Issues/CIRT Call- Out Procedures? (No. D-301) found that CIRT members were given discretion as to when and under what circumstances a MHMRA referral was appropriate, including when an inmate threatened suicide. For example, page 6 of the policy stated that personnel determine the conduct engaged in or exhibited by the inmate is in their opinion (training-base assessment and experience) intentional and deliberate behavioral misconduct (more so than a mental health crisis): a) the scene is released to housing personnel, b) An MHMRA referral is generated by assigned POD personnel for review by mental health providers if deemed necessary by the CIRT, and 0) housing documentation is generated as required.? It would appear from this directive that the HCSO was confident that the training and experience of its CIRT members was suf?cient to distinguish between ?deliberate behavioral misconduct? and a ?mental health crisis.? As such, if an inmate threatened suicide and was initially referred to CIRT, a CIRT member could subsequently determine that the inmate was not suicidal and, therefore, not initiate an emergency referral to MHMRA. It would be this writer?s opinion that there is no amount of training and experience that could be given to non-mental health staff that would equip them to distinguish between deliberate behavioral misconduct and a WORK PRODUCT: EXPERT REPORT ON SUICIDE PREVENTION mental health cries crisis as it related to a suicide threat. Such a determination can only be done 28 by a quali?ed mental health professional. found in the seemingly dichotomous management of inmates 011 suicide precautions, as well as the apparent discretion given to CIRT when initially responding to a crisis call involving a As shown in the following case summaries, there were several concerning practices suicide threat: On May 7, 2014, a detention officer was in the midst of writing a code violation report on an inmate who was found with contraband in his cell when the inmate informed the of?cer that ?he felt that he wants to commit suicide is planning to hang himself.? The inmate was placed in a separation cell and issued a safety smock. A Referral for Screening form was completed and forwarded to the MHMRA. A mental health clinician saw the inmate later that morning and he continued to express suicidal ideation, as well as describe two incidents of previous self-injurious behavior. He did not report a history of mental illness. The inmate was referred to the for further assessment. The assessed the inmate later that day and the inmate continued to endorse suicidal ideation, Despite the fact that the inmate continued to threaten suicide, the viewed the behavior as manipulative and suicide precautions were not continued. The inmate wasreturned to his housing unit, no follow-up assessment was scheduled, and an SRA was not completed. On May 6, 2014, the mother of an inmate who had just exited the Visitor Control Center informed personnel that her son was ?feeling like hurting himself.? The inmate was placed in a separation cell and issued a safety smock. CIRT was noti?ed. Two members of CIRT responded and interviewed the inmate, who ?told us that he was feeling ?ne and was upset because his wife had left him said that he attempted to harm self twice before in the past, and he said that he was diagnosed with Anxiety, Depression and PTSD. He also said that he was feeling ?ne wanted to go back to his cell block so that he can go to Bible study the next morning.? The CIRT then referred the inmate to MHMRA, and the inmate was seen by a clinician the following day (May 7), but suicide precautions were not continued. An SRA was not completed. A review of the medical chart also indicated the inmate had previously expressed ?passive suicidal ideation? to a nurse on April 30, but apparently was not referred to MHMRA. On May 13, 2014, an inmate was involved in an altercation the previous night and was being threatened by other inmates in the housing unit. He threatened suicide to a detention officer who noti?ed CIRT. The inmate was subsequently seen by WORK PRODUCT: EXPERT REPORT ON SUICIDE PREVENTION 29 CIRT, but not placed on suicide precautions and not referred to MHMRA that day, presumably because he subsequently signed a form provided by CIRT that said ?I?m not suicidal.? He was subsequently referred to MHMRA the following day (May 14). (Subsequent review of the medical chart by this writer indicated that the inmate had been in a acute mental health unit the previous June 2013.) On May 13, 2014, an inmate was observed by a detention officer to have cut his shirt collar off and wrap it around the ?re sprinkler head inside of his cell. The of?cer also observed ?a cut on his left upper wrist.? The of?cer then called CIRT and explained the situation and the CIRT member ?informed me that this is not a crisis situation.? The detention of?cer then completed a Referral for Screening form that was forwarded to MHMRA. The inmate was seen later that day by a Nurse Practitioner who wrote a progress note that indicated the inmate was not suicidal, ?but will harm self.? Despite this ?nding, the inmate was not placed on suicide precautions, rather he was released back to general population housing and would be seen again in one week. An SRA was not completed. 0 On April 17, 2014, an inmate informed a detention of?cer that ?they are driving me crazy in here. Ifeel like I want to kill myself. Can you give me a I-60 (inmate request form).? The of?cer called his sergeant who responded to the scene and the inmate again repeated the statement that he ?felt like he wanted to kill himself.? The inmate also reported that he had been refusing his medication because it was ?too strong.? (Subsequent review' of the medical chart by this writer indicated that the inmate had been diagnosed with Disorder and was on several medications.) The sergeant asked the inmate ?if he felt comfortable enough to return to the cell block and the inmate said he felt fine enough to return to the cell block.? The detention officer then completed a Referral for Screening form (but did not directly contact MHMRA that day), and the form was not received by MHMRA until four days later on April 21, 2014. The above cited cases were concerning because they involved examples of untimely referrals to MHMRA (although Referral for Screening forms were completed in many cases), suicide risk assessment forms not completed, follow?up appointments for continued assessment of suicide risk not scheduled, discretion afforded both CIRT members and custody staff regarding MHMRA referrals when inmates threatened suicide, and apparent WORK PRODUCT: EXPERT REPORT ON SUICIDE PREVENTION 30 distinctions made between generally suicidal inmates and inmates who threatened suicide for a perceived secondary gain. '9 With regard to inmates who threaten suicide for a perceived secondary gain, as should be discussed during suicide prevention training workshops, although distinguishable, manipulative behavior and suicidal behavior are not mutually exclusive. Both types of behavior can occur (or overlap) in the same individual and cause serious injury and death. Several studies of self?harm and suicide in the correctional environment have found ?substantial co?existence of manipulative motive with both suicidal intent and potentially high lethality of self?harming behavior.?20 As one observer has stated, ?There are no reliable bases upon which we can differentiate ?manipulative? suicide attempts posing no threat to the inmate?s life from those ?true, non~ manipulative? attempts which may end in death. The term ?manipulative? is simply useless in understanding, and destructive in attempting to manage, the suicidal behavior of inmates (or of anybody else).21 Self-harm is often a complex, multifaceted behavior, rather than simply manipulative behavior motivated by secondary gain. At a minimum, any inmate who would go to the extreme of threatening suicide or engaging in self-harming behavior is suffering from at least an emotional imbalance that requires special attention. They may also be mentally ill. Simply stated, inmates labeled as manipulative still commit suicide. '9It should be noted that these concerns were found not only in the cases reviewed on-site, but in the files of a few inmates who committed suicide in the Harris County Jail System between 2012 and 2014. 20Dear G, Thomson D, Hilis A. (2000), ?Self-Harm in Prison: Manipulators Can Also Be Suicide Attempters,? Criminal Justice and Behavior, 27: 160-175. 2iHaycock J. (1992), ?Listening to ?Attention Seekersz? The Clinical Management of People Threatening Suicide,? Jail Suicide Update 4 (4): 8-11. WORK PRODUCT: EXPERT REPORT ON SUICIDE PREVENTION 31 In addition, the medical chart review found that there was very limited treatment planning for inmates identi?ed as suicidal and/or engaging in self-injurious behavior, and/or a timely schedule for follow-up appointments to assess any continued risk for suicide. standards as well as other national correctional standards, require that a treatment plan ?should describe signs, and the circumstances in which risk for suicide is likely to recur; how recurrence of suicidal thoughts can be avoided, and the actions the patient or staff can take if suicidal thoughts do occur.? As found in the Centricity EMR, a typical treatment plan for an inmate released from suicide precautions would be: discharge suicide precautions, 2) RTC in one week? or ?in 30 days?). RECOMMENDATIONS: This writer would offer several recommendations to strengthen the observation and management of inmates identi?ed as suicidal and/or exhibiting self-injurious behavior within the Harris County Jail System. First, it is strongly recommended that both the HCSO and MHMRA suicide prevention policies should be revised to include two levels of observation that include specific descriptions of behavior warranting each level of observation. A proposed revision is offered as follows: Close Observation is reserved for the inmate who is not actively suicidal, but expresses suicidal ideation and/or has a recent prior history of self-destructive behavior and would be considered a low risk for suicide. In addition, an inmate who denies suicidal ideation or does not threaten suicide, but demonstrates other concerning behavior (through actions, current circumstances, or recent history) indicating the potential for self-injury, should be placed under close observation. This inmate should be observed by staff at staggered intervals not to exceed every 15 minutes, and should be documented as it occurs. Constant Observation is reserved for the inmate who is actively suicidal, either by threatening or engaging in self-injury and would be considered a high risk for suicide. This inmate should be WORK PRODUCT: EXPERT REPORT ON SUICIDE PREVENT ION 32 observed by an assigned staff member on a continuous, uninterrupted basis. The observation should be documented at 15- minute intervals. Second, it is strongly recommended that whenever an inmate threatens suicide and/or is identi?ed by non-mental health staff as being a potential risk for suicide, regardless of the staff?s perception of the genuineness of the behavior, a MHMRA clinician must be immediately noti?ed either in person or by telephone, with documentation subsequently generated by a Referral for Screening form. In other words, CIRT members, detention personnel, and nursing staff should not be allowed to utilize discretion when interpreting an inmate?s threat of suicide. Peltinent HCSO policies, including ?Addressing Inmates with Mental Health Issues/CIRT Call? Out Procedures? (No. D-301), should be revised accordingly. Third, it is strongly recommended that, in addition to all quali?ed mental health professionals within MHMRA be required to complete the Suicide Risk Assessment (SRA) form whenever an inmate is identi?ed and referred for possible suicidal behavior. The SRA should be utilized at least twice, for initiation of suicide precautions, as well as justification for discharging the inmate from suicide precautions. Fourth, it is strongly recommended that the Suicide Risk Assessment (SRA) form embedded in the Centricity EMR be revised by deleting the wording ?within six months? under the ?History of Signi?cant Suicide Attempts? section. All history of suicide attempts is important to solicit, with the clinician utilizing their clinical judgment to determine how signi?cant recent suicide attempts are to the current risk of suicidal behavior. In addition, the ?Static Risk Factor? section of the form should include inquiry of ?Family History of WORK PRODUCT: EXPERT REPORT ON SUICIDE PREVENTION 33 Suicide/Suicide Attempts.? it is strongly recommended that, regardless as to whether the inmate on suicide precautions is housed in the acute mental health unit or a separation unit cell, they should be assessed by a quali?ed mental health professional on a daily basis. In addition to completion of an SRA when an inmate is placed on, or discharge from, suicide precautions, if an inmate is continued on suicide precautions following a daily assessment, mental health clinicians should be required to document justi?cation for continued suicide precautions as a progress note that provides suf?cient description of the current behavior and justi?cation for a particular level of observation. Sixth, it is strongly recommended that, consistent with and other national correctional standards, mental health clinician(s) develop treatment plans for inmates on suicide precautions that ?describe signs, and the circumstances in which the risk for suicide is likely to recur, how recurrence of suicidal thoughts can be?avoided, and actions the patient or staff can take if suicidal thoughts do occur? (see 2008). Seventh, it is strongly recommended that, in order to safeguard the continuity of care for suicidal inmates, all inmates discharged from suicide precautions should remain on mental health caseloads and receive regularly scheduled follow?up assessments by mental health staff until their release from custody. As such, unless an inmate?s individual circumstances directs otherwise (cg, an inmate inappropriately placed on suicide precautions by non-mental health staff and released less than 24 hours later following an assessment), it is recommended that the WORK PRODUCT: EXPERT REPORT ON SUICIDE PREVENTION 34 reassessment schedule following discharge from suicide precautions be as follows: within 24 hours, again within 72 hours, again within 1 week, and then periodically until release from custody. Eighth, it is strongly recommended that, to better ensure inmates on suicide precautions and assigned to single cells within the acute mental health unit cells are receiving appropriate observation, technicians (for other appropriate staff) be required to post the observation forms on the individual cell doors. Such a requirement already exists for inmates on observation status in the separation units. WORK PRODUCT: EXPERT REPORT ON SUICIDE PREVENTION 35 6) Intervention A facility?s policy regarding intervention should be threefold: 1) all staff who come into contact with inmates should be trained in standard first aid and cardiopulmonary resuscitation 2) any staff member who discovers an inmate attempting suicide should immediately respond, survey the scene to ensure the emergency is genuine, alert other staff to call for medical personnel, and begin standard ?rst aid and/or and 3) staff should never presume that the inmate is dead, but rather initiate and continue appropriate life-saving measures until relieved by arriving medical personnel. In addition, all housing units should contain a first aid kit, pocket mask or mouth shield, Ambu bag, and rescue tool (to quickly cut through fibrous material). All staff should be trained in the use of the emergency equipment. Finally, in an effort to ensure an efficient emergency response to suicide attempts, ?mock drills? should be incorporated into both initial and refresher training for all staff. Following a suicide attempt, the degree and promptness of intervention provided by staff often foretells whether the victim will survive. Although both ACA and standards address the issue of intervention, neither are elaborative in offering speci?c protocols. For example, ACA Standard requires that -- ?Correctional and health care personnel are trained to respond to health?related situations within a four-minute response time. The training the following: recognition of signs and and knowledge of action required in potential emergency situations; administration of basic ?rst aid and certification in cardiopulmonary resuscitation Standard states ?Intewentionz There are procedures addressing how to handle a suicide attempt in progress, including appropriate ?rst-aid measures.? FINDINGS: The HCSO suicide prevention policies provide very good descriptions of the proper emergency reSponse to a suicide attempt. In addition, ?rst aid kits were located in WORK PRODUCT: EXPERT REPORT ON SUICIDE PREVENTION 36 most housing units that were toured by this writer. Each kit contained a microshield or CPR mask. In addition, emergency rescue tools (utilized to quickly cut through ?brous material), were also found in most toured units. According to training data reviewed by this writer, approximately 73% of custody staff, and 100% of both medical and mental health personnel, were currently certi?ed in cardiopulmonary resuscitation This writer?s review of investigative ?les and medical charts of two inmates that committed suicide between 2012 and 2014 indicated questionable CPR practices by custody staff, e. CPR initiated while the ligature was still wrapped around the victim?s neck in one case, and CPR initiated by custody staff but then stopped prior to arrival of nursing staff in another case. RECOMMENDATION: Only one recommendation is offered. It is strongly recommended that the compliance rate of training for custody personnel be increased from 73% (to over 7) Reporting In the event of a suicide attempt or suicide, all appropriate correctional officials should be notified through the chain of command. Following the incident, the victim?s family should be immediately notified, as well as appropriate outside authorities. All staff who came into contact with the victim prior to the incident should be required to submit a statement as to their full knowledge of the inmate and incident. FINDINGS: This writer?s review of the investigative reports concerning the recent inmate suicides found that all reporting requirements appeared to have been appropriately followed. 22T he percentage for custody staff excludes new employees. WORK PRODUCT: EXPERT REPORT ON SUICIDE PREVENTION 37 RECOMMENDATION: None 8) Follow-un/Morbiditv-Mortalitv Review Eveiy completed suicide, as well as serious suicide attempt requiring hospitalization), should be examined by a morbidity- mortality review. (If resources permit, clinical review through a autopsy is also recommended.) The review, separate and apart from other formal investigations that may be required to determine the cause of death, should include: 1) review of the circumstances surrounding the incident; 2) review of procedures relevant to the incident; 3) review of all relevant training received by involved staff; 4) review of pertinent medical and mental health services/reports involving the victim; 5) review of any possible precipitating factors that may have caused the victim to commit suicide or suffer a serious suicide attempt; and 6) recommendations, if any, for changes in policy, training, physical plant, medical or mental health services, and operational procedures. Further, all staff involved in the incident should be offered critical incident stress debriefing. Experience has demonstrated that many correctional systems have reduced the likelihood of future suicides by critically reviewing the circumstances surrounding incidents as they occur. While all deaths are investigated either internally or by outside agencies to ensure impartiality, these investigations are normally limited to determining the cause of death and whether there was any criminal wrongdoing. The primary focus of a morbidtty~mortality review should be two- fold: tie-m: happened in the case under review and what can be learned to help prevent ?it-we incidents? To be successful, the morbidity~morta1ity review team must be multidisciplinaiy and include representatives of both line and management level staff from the corrections, medical and mental health divisions. WORK PRODUCT: EXPERT REPORT ON SUICIDE PREVENTION 38 FINDINGS: The HCSO suicide prevention policies provide very good descriptions of the review process following an inmate suicide or serious suicide attempt, including the responsibility of the Suicide Prevention Committee which was established in January 2014. Each suicide (and any other death in the jail system) results in an investigation by the Homicide Division of the Harris County Sheriff?s Of?ce. This writer reviewed most of the investigative reports for each of the recent inmate suicides and found them to be quite thorough. In addition, each suicide results in a ?Internal Quality Improvement Death Review? conducted by the Executive Director of Health Services Detention Bureau. Review of several of these documents found them also to be quite thorough. Finally, multidisciplinary mortality reviews through a Suicide Prevention Committee has been conducted following each inmate suicide since January 2014. The Committee, comprising executive and management staff from custody and medical divisions of the HCSO, as well as regularly meets on a quarterly basis, as well as following any inmate suicide or serious suicide attempt. Meetings are facilitated by the Captain of Administrative Services, Criminal Justice Command. The HCSO General Counsel also attends each committee meeting. Review of several of these documents found them also to be quite thorough. The only noted concern was that documentation of discussion/reconmiendations offered by the Committee did not always contain any indication as to whether such recommendations were accepted or rejected, as well as a corrective action plan with responsible parties and timetables for completion noted for these recommendations accepted by the Committee andlor HCSO and MHMRA of?cials. WORK PRODUCT: EXPERT REPORT ON SUICIDE PREVENTION 39 RECOMMENDATIONS: Only one recommendation is offered. It is strongly recommended that documentation of a Suicide Prevention Committee recommendation should contain an indication as to whether or not the recommendation was accepted or rejected, as well as a corrective action plan with responsible parties and timetables for completion noted for any recommendation accepted by the Committee and/or HCSO and MHMRA of?cials. WORK PRODUCT: EXPERT REPORT ON SUICIDE PREVENTION 40 C. SUMMARY OF RECOMMENDATIONS Staff Trainin 1) It is strongly recommended that the HCSO require that all new employees complete the 8-hour ?Suicide Detection and Prevention in Jails: Course No. 3501? classroom-instructed training developed by TCLEOSE. 2) Suicide prevention is all about pro-active attitudes and collaboration, principles that are lost sitting alone in a chair at a computer terminal. As such, it is strongly recommended the HCSO and MHMRA require classroom-instructed annual suicide prevention training and that both agencies collaborate on a 2?hour curriculum that includes the following topics: avoiding obstacles (negative attitudes) to prevention inmate suicide research why facility environments are conducive to suicidal behavior identifying suicide risk despite the denial of risk potential predisposing factors to suicide high?risk suicide periods warning signs and components of the suicide prevention program Intake Screening/Assessment 3) It is strongly that the current suicide risk inquiry contained on the current ?Intake Health Screening? in the Centricity EMR be enlarged to include the following: 0 Have you ever attempted suicide? 0 Have you ever considered suicide? 0 Are you now or have you ever been treated for mental health or emotional problems? 0 Have you recently experienced a signi?cant loss (relationship, death of family member/close friend, job, etc.)? 0 Has a family member/close friend ever attempted or committed suicide? 0 Do you feel there is nothing to look forward to in the immediate ?iture (inmate expressing helplessness and/or hopelessness)? - Are you thinking of hurting and/or killing yourself? 4) It is strongly recommended that the HCSO Health Services Detention Bureau initiate a continuous quality assurance audit of the intake screening process to ensure that newly admitted inmates are receiving adequate privacy and that all intake questions are being asked by nursing staff as required. WORK PRODUCT: EXPERT REPORT ON SUICIDE PREVENTION 41 5) Regardless of the inmate?s behavior or answers given during intake screening, an immediate referral to mental health staff should always be initiated based on documentation re?ecting possible mental illness and/or suicidal behavior during an inmate?s prior con?nement within the HCSO. As such, the ?alert screen? should be activated within the Centricity EMR according to the following procedures: 0 Any inmate placed on suicide precautions should be tagged on the ?alert screen? of the Centricity EMR by mental health staff; 0 Nursing staff conducting intake screening should always review the inmate?s alert screen to verify whether they were previously con?ned in the HCSO and had any history of suicidal behavior/placement on suicide precautions during a prior con?nement; and Regardless of the inmate?s behavior or answers given during intake screening, an immediate referral to mental health staff should always be initiated based on documentation re?ecting possible mental illness and/or suicidal behavior during an inmate?s prior con?nement within the HCSO. 6) It would be strongly recommended that HCSO and Harris County Pre?Trial Services of?cials collaborate on deveIOping a formal mechanism of referral. Communication None Housing 7) It is strongly recommended that HCSO of?cials embark upon an inspection program to ensure that inmates on suicide precautions are housed in ?suicide- resistant? cells, without any obvious protrusions that would easily enable an inmate to hang themselves. For example, bunk holes should be covered and/0r bunk replaced, dangerous ventilation grates be replaced with grates that have holes that are ideally 1/8 inches in diameter and no more than 3/16 inches diameter (or 16?mesh per square inch), and smoke detector and sprinkler head covers should be ?ush with the ceiling, and gaps between light ?xtures and ceilings should be covered with security caulking. Speci?c recommendations regarding the removal of obvious protrusions in cells can be found in the ?Checklist for the ?Suicide?Resistant? Design of Correctional Facilities,? which is contained in Appendix A of this report. 8) It is strongly recommended that the policies be revised to include the following requirements: WORK PRODUCT: EXPERT REPORT ON SUICIDE 42 0 All decisions regarding the removal of an inmate?s clothing, bedding, possessions (books, slippers/sandals, eyeglasses, etc.) and privileges shall be commensurate with the level of suicide risk as deter'rrzined on a case- by-case basis by mental health stajj?; - If mental health staff determine that an inmate?s clothing needs to be removed for reasons of safety, the inmate shall always be issued a safety smock and safety blanket; A mattress shall be issued to all inmates on suicide precautions unless the inmate utilizes the mattress in ways in which it was not intended attempting to tamper with/destroy, utilizes to obstruct visibility into the cell, etc.); All inmates on suicide precautions shall be allowed all routine privileges family visits, telephone calls, unless the inmate has lost those privileges as a result of a disciplinary sanction; and Inmates on suicide precautions shall not automatically be locked down. They should be allowed dayroom access commensurate with their security level and clinical judgment of mental health staff. Levels of Supervision/Management 9) It is strongly recommended that both the H080 and MHMRA suicide prevention policies should be revised to include two levels of observation that include specific descriptions of behavior warranting each level of observation. A proposed revision is offered as follows: Close Observation is reserved for the inmate who is not actively suicidal, but expresses suicidal ideation and/or has a recent prior history of self-destructive behavior and would be considered a low risk for suicide. In addition, an inmate who denies suicidal ideation or does not threaten suicide, but demonstrates other concerning behavior (through actions, current circumstances, or recent history) indicating the potential for self-injury, should be placed under close observation. This inmate should be observed by staff at staggered intervals not to exceed every 15 minutes, and should be documented as it occurs. Constant Observation is reserved for the inmate who is actively suicidal, either by threatening or engaging in self?injury and would be considered a high risk for suicide. This inmate should be observed by an assigned staff member on a continuous, uninterrupted basis. The observation should be documented at 15?minute intervals. WORK PRODUCT: EXPERT REPORT ON SUICIDE PREVENTION 43 10) It is strongly recommended that whenever an inmate threatens suicide and/or is identi?ed by non-mental health staff as being a potential risk for suicide, regardless of the staff?s perception of the genuineness of the behavior, a MHMRA clinician must be immediately noti?ed either in person or by telephone, with documentation subsequently generated by a Referral for Screening form. In other words, CIRT members, detention personnel, and nursing staff should not be allowed to utilize discretion when interpreting an inmate?s threat of suicide. Pertinent HCSO policies, including ?Addressing Inmates with Mental Health Issues/CIRT Call-Out Procedures? (No. D-301), should be revised accordingly. 11) It is strongly recommended that, in addition to all quali?ed mental health professionals within MHMRA be required to complete the Suicide Risk Assessment (SRA) form whenever an inmate is identi?ed and referred for possible suicidal behavior. The SRA should be utilized at least twice, for initiation of suicide precautions, as well as justi?cation for discharging the inmate from suicide precautions. 12) It is strongly recommended that the Suicide Risk Assessment (SRA) form embedded in the Centricity EMR be revised by deleting the wording ?within six months? under the ?History of Signi?cant Suicide Attempts? section. All history of suicide attempts is important to solicit, with the clinician utilizing their clinical judgment to determine how signi?cant recent suicide attempts are to the current risk of suicidal behavior. In addition, the ?Static Risk Factor? section of the form should include inquiry of ?Family History of Suicide/Suicide Attempts.? 13) It is strongly recommended that, regardless as to whether the inmate on suicide precautions is housed in the acute mental health unit or a separation unit cell, they should be assessed by a quali?ed mental health professional on a daily basis. In addition to completion of an SRA when an inmate is placed on, or discharge from, suicide precautions, if an inmate is continued on suicide precautions following a daily assessment, mental health clinicians should be required to document justi?cation for continued suicide precautions as a progress note that provides suf?cient description of the current behavior and justi?cation for a particular level of observation. 14) It is strongly recommended that, consistent with and other national correctional standards, mental health clinician(s) develop treatment plans for inmates on suicide precautions that ?describe signs, and the circumstances in which the risk for suicide is likely to recur, how recurrence of suicidal thoughts can be avoided, and actions the patient or staff can take if suicidal thoughts do occur? (see 2008). 15) It is strongly recommended that, in order to safeguard the continuity of care for suicidal inmates, all inmates discharged from suicide precautions should WORK PRODUCT: EXPERT REPORT ON SUICIDE PREVENTION 44 remain on mental health caseloads and receive regularly scheduled follow-up assessments by mental health staff until their release from custody. As such, unless an inmate?s individual circumstances directs otherwise an inmate inappropriately placed on suicide precautions by non?mental health staff and released less than 24 hours later following an assessment), it is recommended that the reassessment schedule following discharge from suicide precautions be as follows: within 24 hours, again within 72 hours, again within 1 week, and then periodically until release from custody. 16) It is strongly recommended that, to better ensure inmates on suicide precautions and assigned to single cells within the acute mental health unit cells are receiving appr'Opriate observation, technicians (for other appropriate staff) be required to post the observation forms on the individual cell doors. Such a requirement already exists for inmates on observation status in the separation units. Intervention 17) It is strongly recommended that the compliance rate of training for custody personnel be increased from 73% (to over Reporting None Folloxqun/Morbiditv-Mortalitv Review 18) It is strongly recommended that documentation of a Suicide Prevention Committee recommendation should contain an indication as to whether or not the recommendation was accepted or rejected, as well as a corrective action plan with responsible parties and timetables for completion noted for any recommendation accepted by the Committee and/or HCSO and MHMRA officials. WORK PRODUCT: EXPERT REPORT ON SUICIDE PREVENTION 45 D. CONCLUSION It is hoped that the suicide prevention assessment provided by this writer, as welle recommendations contained within this report, will be of assistance to both the Harris (ty Sherist Of?ce and Mental Health and Mental Retardation Authority of Harris CourAs stated in the preface of this report, both agencies have adequate comprehensive :ide prevention policies. a low jail suicide rate. It is several suicide pretion practices that were of concern. However, this writer met numerous HCSO and MARA of?cials and supervisors, as well as of?cers and mental health clinicians, who geared genuinely concerned about inmate suicide and committed to taking whatever actios Were necessary to reduce the opportunity for such tragedy in the future. In fact, and as previously indicated, some corrective actions were already made on?site through the leadership of the Executive Director of Health Services Detention Bureau. And based upon a pro-active approach and high caliber management and line staff, this writer is con?dent that full implementation of the recommendations contained within this report will result in successful efforts to reduce the likelihood of future inmate suicides within the Harris County Sheriff? 3 Of?ce. In conclusion, this writer would be remiss by not extending sincere appreciation to Adrian Garcia, Sheriff; Jim Leitner, HCSO General Counsel; Michael M. Seale, MD, EXecutive Director, HCSO Health Services Detention Bureau, and Robert M. Simon, Jail Mental Health Administrator for MHMRA of Harris County. Special thanks is extended to Ronny R. Taylor, Captain, HCSO Administrative Services, Criminal Justice Command. Without the total candor, cooperation and assistance these individuals, as well as from all correctional, medical, and WORK PRODUCT: EXPERT REPORT ON SUICIDE PREVENTION 46 mental health personnel that were interviewed, this writer would not have been able to complete this technical assistance assignment. Respectfully Submitted By: s/s Lindsay M. Hayes Lindsay M. Hayes June 8, 2014 WORK PRODUCT: EXPERT REPORT ON SUICIDE PREVENTION 47 APPENDIX A CHECKLIST FOR THE DESIGN OF CORRECTIONAL FACILITIES Lindsay M. Hayes ?National Center on Institutions and Alternatives, 2012 The safe housing of suicidal inmates is an important component to a correctional facility?s comprehensive suicide prevention policy. Although impossible to create a ?suicide-proof? cell environment within any correctional facility, given the fact that almost all inmate suicides occur by hanging, it is certainly reasonable to ensure that all cells utilized to house potentially suicidal inmates are free of all obvious protrusions. And while it is more common for ligatures to be af?xed to air vents and window bars (or grates), all cell ?xtures should be scrutinized, since bed frames/holes, shelves with clothing hooks, sprinkler heads, door hinge/knobs, towel racks, water faucet lips, and light ?xtures have been used as anchoring devices in hanging attempts. As such, to ensure that inmates placed on suicide precautions are housed in ?suicide-resistant? cells, facility of?cials are strongly encouraged to address the following architectural and environmental issues: 1) Cell doors should have large-vision panels of Lexan (or low-abrasion polycarbonate) to allow for unobstructed View of the entire cell interior at all times. These windows should be covered (even for reasons of privacy, discipline, etc.) If door sliders are not used, door interiors should not have handles/knobs; rather they should have recessed door pulls. Any door containing a food pass should be closed and locked. Interior door hinges should bevel down so as not to permit being used as an anchoring device. Door frames should be rounded and smooth on the top edges. The frame should be grouted into the wall with as little edge exposed as possible. In older, antiquated facilities with cell fronts, walls and/or cell doors made of steel bars, Lexan paneling (or low-abrasion polycarbonate) or security screening (that has holes that are ideally 1/8 inches wide and no more than 3/16 inches wide or 16-mesh per square inch) should be installed from the interior of the cell. Solid cell fronts must be modi?ed to include large-vision Lexan panels or security screens with small mesh; 2) Vents, ducts, grilles, and light ?xtures should be protrusion-free and covered with screening that has holes that are ideally 1/8 inches Wide, and no more than 3/16 inches wide or 16 -mesh per square inch; 3) If cells have ?oor drains, they should also have holes that are ideally 1/8 inches wide, and no more than 3/16 inches wide or l6-mesh per square inch (inmates have been known to weave one end of a ligature through the ?oor drain with the other end tied WORK PRODUCT: EXPERT REPORT ON SUICIDE PREVENTION 48 around their neck, then lay on the floor and spin in a circular motion as the ligature tightens); 4) Wall-mounted corded telephones should n_ot be placed inside cells. Telephone cords of varying length have been utilized in hanging attempts; 5) Cells should n_ot contain any clothing hooks. The traditional, pull-down or collapsible hook can be easily jammed and/or its side supports utilized as an anchor; 6) A stainless steel combo toilet?sink (with concealed plumbing and outside control valve) should be used. The ?xture should n_ot contain an anti-squirt slit, toothbrush holder, toilet paper rod, and/or towel bar; 7) Beds should ideally be either heavy molded plastic or solid concrete slab with rounded edges, totally enclosed underneath. If metal bunks are utilized, they should be bolted ?ush to the wall with the frame constructed to prevent its use as an anchoring device. Bunk holes should be covered; ladders should be removed. (Traditional metal beds with holes in the bottom, not built ?ush to the wall and open underneath, have often been used to attach suicide nooses. Lying ?at on the ?oor, the inmate attaches the noose from above, runs it under his neck, turns over on his stomach and himself within minutes); 8) Electricity should be turned off from wall outlets outside of the cell; 9) Light ?xtures should be recessed into the ceiling and tamper-proof. Some ?xtures can be securely anchored into ceiling or wall corners when remodeling prohibits recessed lighting. All fixtures should be caulked or grouted with tamper-resistant security grade caulking or grout. Ample light for reading (at least 20 foot-candles at desk level) should be provided. Low-wattage night light bulbs should be used (except in special, high-risk housing units where suf?cient lighting 24 hours per day should be provided to allow closed-circuit television (CCTV) cameras to identify movements and forms). An alternative is to install an infrared filter over the ceiling light to produce total darkness, allowing inmates to sleep at night. Various cameras are then able to have total observation as if it were daylight. This ?lter should be used only at night because sensitivity can otherwise develop and produce a?ereffects; 10) CCTV monitoring does mt prevent a suicide, it only identifies a suicide attempt in progress. If utilized, CCTV monitoring should only supplement the physical observation by staff. The camera should obviously be enclosed in a box that is tamper-proof and does not contain anchoring points. It should be placed in a high corner location of the cell and all edges around the housing should be caulked or grouted. WORK PRODUCT: EXPERT REPORT ON SUICIDE PREVENTION 49 Cells containing CCTV monitoring should be painted in pastel colors to allow for better visibility. To reduce camera glare and provide a contrast in monitoring, the headers above cell doors should be painted black or some other dark color. CCTV cameras should provide a clear and unobstructed view of the entire cell interior, including four corners of the room. Camera lens should have the capacity for both night or low light level vision; 11) Cells should have a smoke detector mounted flush in the ceiling, with an audible alarm at the control desk. Some cells have a security screening mesh to protect the smoke detector from vandalism. The protective coverings should be high enough to be outside the reach of an inmate and far enough away from the toilet so that the fixture could not be used as a ladder to access the smoke detector and screen. Ceiling height for new construction should be 10 feet to make such a reasonable accommodation. Existing facilities with lower ceilings should carefully select the protective device to make sure it cannot be tampered with, or have mesh openings large enough to thread a noose through. Water sprinkler heads should not be exposed. Some have protective cones; others are ?ush with the ceiling and drop down when set off; some are the breakaway type; 12) Cells should have an audio monitoring intercom for listening to calls of distress (oily as a supplement to physical observation by staff). While the inmate is on suicide precautions, intercoms should be turned up high (as hanging victims can often be heard to be gurgling, gasping for air, their body hitting the wall/?oor, etc.); 13) Cells utilized for suicide precautions should be located as close as possible to a control desk to allow for additional audio and visual monitoring; 14) If modesty walls or shields are utilized, they should have triangular, rounded or sloping tops to prevent anchoring. The walls should allow visibility of both the head and feet; 15) Some inmates hang themselves under desks, benches, tables or stools/pull-out seats. Potential suicide-resistant remedies are: Extending the bed slab for use as a seat; Cylinder?shaped concrete seat anchored to ?oor, with rounded edges; Triangular corner desk top anchored to the two walls; and Rectangular desk top, with triangular end plates, anchored to the wall. Towel racks should also be removed from any desk area; 16) All shelf tops and exposed hinges should have solid, triangular end?plates which preclude a ligature being applied; 17) Cells should have security windows with an outside view. The ability to identify time of day via sunlight helps re-establish perception and natural thinking, while minimizing disorientation. WORK PRODUCT: EXPERT REPORT ON SUICIDE PREVENTION 50 If cell windows contain security bars that are not completely ?ush with window panel (thus allowing a gap between the glass and bar for use as an anchoring device), they should be covered with Lexan (or low-abrasion polycarbonate) paneling to prevent access to the bars, or the gap, should be closed with caulking, glazing tape, etc. If window screening or grating is used, covering should have holes that are ideally 1/8 inches wide, and no more than 3/16 inches wide or l6-rnesh per square inch; 18) The mattress should be ?re retardant and not produce toxic smoke. The seam should be tear-resistant so that it cannot be used as a ligature; 19) Given the fact that the risk of self-harm utilizing a laundry bag string outweighs its usefulness for holding dirty clothes off the ?oor, laundry bag strings should be removed from the cell; 20) Mirrors should be of brushed, polished metal, attached with tamper-proof screws; 21) Padding of cell Walls is prohibited in many states. Check with your ?re marshal. If permitted, padded walls must be of ?re-retardant materials that are not combustible and do not produce toxic gasses; and 22) Ceiling and wall joints should be sealed with neoprene rubber gasket or sealed with tamper-resistant security grade caulking or grout for preventing the attachment of an anchoring device through the joints. NOTE: A portion of this checklist was originally derived from R. Atlas (1989), ?Reducing the Opportunity for Inmate Suicide: A Design Guide,? Quarterly, 60 (2): 161-171. Additions and modi?cations were made by Lindsay M. Hayes, and updated by Randall Atlas, a registered architect. See also Hayes, L.M. (2003), ?Suicide Prevention and ?Protrusion? Free Design of Correctional Facilities,? Jail Suicide/Mental Health Update, 12 (3): 1-5. Last revised Mr. Hayes in February 2012. WORK PRODUCT: EXPERT REPORT ON SUICIDE PREVENTION