BRISTOL COUNTY HOUSE OF CORRECTIONS INTERNAL REVIEW OF COMPLETED SUICIDES At the request of the Sheriff, Correctional Services, the BCSO contractual health care provider along with the Medical Department of the BCSO undertook a review of inmate suicides and suicidal prevention protocols over the last two years. The last several years have demonstrated a sharp increase in prison suicides nationwide which most professionals attribute to the escalading opioid epidemic in the country. SCOPE OF REPORT This report examined the suicide history at the BCSO for the period of 05/06/2015 through 06/10/2017. During this time period the department experienced 7 completed suicides of inmates.I Of these suicides there were six males and one female with ages ranging from 21 to 48 years old. All seven had a history of prior incarcerations/admissions and all killed themselves by hanging. In Part I of this review, we studied the following factors: Nature of incarceration; detoxification status; family support; notice of potential suicidality; and lock-up/segregation status. In Part II, the report reviews suicide prevention initiatives and modalities that have been put in place at the BCSO. 1 There was a completed suicide ofa Regional admission that is not factored in the internal review as there was incomplete background PART I NATURE OF THE INCARCERATIONS Five of 7 inmates were being held pre-trial facing major felony charges in the Superior Court. Three were charged with armed robbery while masked, one for assault to murder and one for the rape of a minor. One was being held on the charge of child endangerment and operating under the influence of alcohol and the last one was charged with grand larceny. Three were held without bail, and three were held with high cash bails of$100,000, $150,000 and $250,000. Only one inmate was held on lower bail in the amount of $500 cash. Six of the inmates were charged with crimes of Violence realistically expectant of doing time after trial, five looking at State Prison Time. DE TOXIFICATION STATUS At the time ofthe suicides, two ofthe inmates were just completing a detox protocol and two had just concluded detox. The three others Were longer term inmates in the system and had already undergone detox either at the BCSO or at another penal facility. Accordingly, all of the seven had a history of substance abuse. I FAMILY SUPPORT Significant issues arising interfamilial relationships with the inmates appear to precede the suicides. l. The inmate with relatively low bail committed suicide sh01tly after his family refused to pay his bail. 2. Just prior to the Suicide, an inmate had a contentious telephone call from a signi?cant other about putting money in the inmate?s canteen. 3. The day prior to the suicide an inmate had a Visit from a significant other and their children. 4. Just prior to the suicide, the signi?cant other had failed to put money in the inmates canteen as the inmate requested. 5. One inmate facing a potential long prison sentence had no family Visits. 6. One inmate had only attorney Visits. 7. Only one inmate appeared to have family support and Visitation. Prior to the suicides on no occasion did any family members report any concerns about suicide. LOCK IN STATUS (LE. Locking Door) Six inmates were on ?lock?in? status for various reasons: threats to hospital and security staff and assaulting other inmates, another inmate recent entry into detox protocol and pending the outcome of D-Reports. One inmate was housed in a single cell as there are only single cells at Ash St. Jail. The others were housed in double bunked cells but for unrelated reasons such as the roommate being at court or recently released, were alone at the time of the suicides. ONLY 2 OF THE INMATES WHO COMMITTED SUICIDE WERE IN ISOLATED SEGRATION PRIOR HISTORY Four of the I inmates had no prior history of either admissions or suicide attempts, nor had made any threats of suicide prior to committing Suicide. One inmate had a self-reported attempt in 2008. One had admissions in 2008 and 2012 with a self-reported suicide attempt in 2016.. The six inmates were screened by mental health personnel on admission, did not express any suicidal ideations and were not deemed to be a suicide risk. One inmate who had a prior attempt at the BCSO in 2015 was on a 15 minute mental health watch in an area serving as an extension of HSU. The inmate was in a Safety Smock and had tucked a sheet strip which was used in the completed suicide. MORTALITY REVIEW All inmate deaths were subject by accreditation standards to a mortality review within 30 days. The ?ndings were all medical, mental health and security standards and procedures were met. PART II SUICIDE PREVENTION ESTABLISHED INITIATIVES, REDUCTION PLAN, AND CHALLENGES OVERVIEW Since 2010 the most signi?cantchanges in the BCSO inmate population are the number of inmates reported using substances. Speci?cally, in 2010 1,900 inmates reported abusing substances upon admission. Just 6 years later 3,341. inmates reported using substances upon admission, resulting in a. 76% increase in just 6 years. Although comparisons with other Massachusetts county prisons are difficult due to the lack of data, we can fairly estimate that in comparison with counties of a similar size, Bristol County detoxes approximately 2/3 more inmates than other similar counties. Additionally, detoxes at the BCSO tend to be prolonged complex detoxes with a high percentage of inmates. Moreover, BCSO inmates are'admitted and diagnosedwith Chronic Disease at rates of 3 times more than that of similar sized counties. The finding of the co-morbidity of chronic disease and substance abuse is likely secondary to long term chronic use of alcohol and drugs. THE DARTMOUTH BEHAVIORAL UNIT (DBU) The BCSO with the assistance of CPS our contractual vendor established the Dartmouth Behavioral Unit (DBU) for the male population. The DBU was initiated in August of 2015 and located in ED unit, and at present, is the only Behavioral Unit of its kind in the county correctional system. The unit itself was modified structurally to create a more suicide resistant environment to house additional mental health. watches from the over?ow of the Health Services Unit. The mezzanine cells of the unit in suicide resistant cells hold participants in the DBU. These individuals meet certain criteria established based on self-harm behaviors and represent a higher risk of inmate who due to these behaviors are involved in frequent med runs and have the potential to escalate to the point of making a serious suicide attempt. Cognitive Behavioral Therapy, Therapeutic Programming and a Phase and Point reward system address the inmate?s speci?c needs with the goal. of reducing those self?harm attempts and then transitioning the inmate back to a successful reintegration to general population. Each inmate selected to participate has their own treatment plan based on their individual needs. Those inmates who successfully completed the program were able to remain in general population with no substantial issues. DBU placement has been offered to other counties who haVe problematic inmates. To date there have been 21 participants in the DBU. This includes the BCSO inmates and the 10 transferred inmates from counties such as Barnstable (3 inmates), Plymouth (4 inmates), Middlesex (1 inmate), and Worcester (1 inmate). These inmates were unmanageable in their own county due to self-harm, assaulting staff, and destruction of property. Seven of the 21 participants graduated the program. Four were sent back to their county of origin due to their refusal to participate in or complete the program. The remaining 8 were released from BCSO by the courts either via a plea up state to the DOC or by other court prOcedures. BCSO has received feedback from those counties to which inmates were returned for failing to comply or complete the program that indicates that despite non-completion, marked behavioral improvement was observed. The DBU currently has two participants transferred from Plymouth County engaged in treatment at this time. Due to the success of the DBU a women?s program modeled off the DBU has been established since March of 201 7 and the EA Unit has been the designated location for those inmates who meet the clinical criteria to participate. The goals are the same as the DBU and each female inmate who participates has her own treatment plan. The ?rst female graduated on July 21, 2017 and was granted parole to a substance abuse/parenting treatment program. A second female participant who was on Phase 2 of the program was sentenced on her outstanding case and sent to the DOC Framingham facility. TREATMENT OUTSIDE OF THE DBU For inmates who do not meet the criteria for admission into the DBU, the BCSO has procured Opioid grant funding to treat opiate and mentally ill offenders in the jail population. This has added mental health staff hours and pre-trial and sentenced groups to address these issues with the population while they are within our custody. PHYSICAL PREVENTATIVE MEASURES In ea1ly 2017, the following structural changes were instituted as suicide p1evention measures: 1. 2. LARGER WINDOWS INSTALLED IN ED CELLS AND G4 TO INCREASE VISIBILITY FOR THOSE ON MENTAL HEALTH WATCH LARGER WINDOWS INSTALLED IN EA CELLS G2 AND G3 FOR BETTER VISIBILITY FOR WOMEN IN SEGREGATION WHO MAY BE ON A WATCH OR DETOXING LARGER WINDOWS IN HSU CELL 3 FOR INCREASED VISIBILTY OF INMATES. ESTABLISHMENT OF A SPECIALIZED REVIEW COMMITTEE Although every death at BCSO is reviewed and scrutinized through a mortality review occurring within 30 days of the date of death a new specialized Committee was established to supplement the mortality review and ?nd new and inventive ways to prevent suicide and address the needs of our population. To date, the Committee has implemented the following changes: 1.. Us ran as Revision of the Segregation screening form revised to include contacting mental health immediately on or off site if the screen is positive for: Inmate is agitated Inmate communication is incoherent History of suicide attempts . Histo1y of detOx protocol 111 past 14 days Current meds Current suicide ideation and .Mental Health Watch Placement 1n the past month .In NovembeI 2016 f01n1al commencement of Mental Health 2recommending to classification ?do not house alone? following Mental Health Watch Clearance .Implementation of a Suicide prevention software pilot program. . Beginning in' late 2016, Extra coordination with Boards/Classi?cation personnel regarding inmates who incur D-reports related todetox/acute issues with the .. emphasis of determining whether segregation discipline should be delayed or suspended until the inmate is medically stabilized. - - . Having an assessment performed for inmates placed on ASO or Awaiting Action Status and are being moved to PE Unit. This is an additional assessment as we were already doing segregation assessments. It is meant to identify potentially high risk inmates who may be placed in a locking unit and have some uncertainty due to their status. . Mental Health has conducted specialized training with our Transportation Officers, Dispatch Personnel, intake team and caseworkers to assist with identifying high risk inmates who may be struggling or may have received bad news at court or during the intake process. Sign in sheets were used for attendance and all three shifts were trained. . Holiday reminders to staff regarding vigilance to inmates in units who may be struggling during the holiday season. .Case conferences between BCSO staff and mental health regarding inmates identified as high risk due to previous suicidal behavior. . Suicide Prevention Pamphlets are now given to inmates during the booking process, medical intake and/or the caseworker intake process. Inmates who are screened by medical for segregation/or ASO or Awaiting Action Status also receive the pamphlet an additional time once screened by medical. STAFFING ADDITIONS CPS has provided 6 full time mental health employees not including the extra staff available due to grant monies. Many of the additional staff has numerous years in the ?eld and with training in the DOC. During ACA, ICE and Accreditations, BCSO and CPS have received top marks in performance and have been recognized by auditors and ICE as being experts in dealing with difficult to manage inmates. FUTURE HALLENGES Based on the fact that the opioid crisis continues to Spiral out of control raising the risk of suicide among the general population as well as the prison population, the following factors present future challenges and goals. 1. Limited housing and limited space for inmates who are admitted and are potential suicidal risks. 2. Development of a specialized Orientation unit to triage new admissions for a longer period than the initial screening. 3. The expected increase in mentally ill inmates due to the closing of DMH facilities. 4. Increasing number of admissions requiring detox. At present the BCSO has detox numbers that rival Masac. Masac has an average census of 200 with approximately 8 admissions a day. They have 64 Full Time Employees. We at BCSO have an average of20 plus admissions per day this is almost 3 times the admissions of Masac. As of June 16, 2017 BCSO has 30 active detoxes on site that require specialized monitoring. is) CONCLUSIONS Given our data and the data nationwide, it does appear there is a very strong direct correlation between substance abuse, (especially opioids and alcohol) and suicidal behavior resulting in completed suicides. The number of suicides at the BCSO during the time studied, although high in number, does not represent a statistically significant difference with increased suicidal rates observed - nationally when the additional factor of substance abuse is incorporated. There is at least anecdotal evidence of a correlation between inter-familiar traumatic events and suicides. Our data indicates that in these cases, here a BCSO, there was no correlation between segregation status and the completed suicides Six of the inmates in question were screened by mental health professionals and did not express any suicidal ideations. The one inmate who was deemed. to be at risk was placed on a 15 minute watch status, by medical and the suicide occurred during watch interval In no cases weie BCSO security staff found not to have been performing their normal rounds or in breach of any other security policies. 6. Recent measures put in place to lessen further suicide attempts appear to be working well and should be continued. Given the likelihood of the prevalence of inmate suicide to increase due to the increasing opioid problem in Bristol County, if funding can be procured to implement the recommended changes in this report, the risk of inmate suicide should decrease. ?This report was prepared in August, 2017 and has been updated with DBU and DWBU statistics as of January 11, 2018. Resp peettully Submitted on January 12, 2018. do. Jorge Veliz, MD President Corree ional Services, PC Ju A. Borges Director 0. t'Medical Services BCSO