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Stafford, Virginia
(NIC T.A. No. 03-J1156)
A. INTRODUCTION
The following is a summary of the observations, findings, and recommendations of Lindsay M. Hayes, Project Director of the National Center on Institutions and Alternatives, following the provision of short-term technical assistance to the Rappahannock Regional Jail.
As of July 2003, the Rappahannock Regional Jail had experienced three (3) inmate suicides since October 2002. Prior to that, the agency had not sustained an inmate suicide in recent memory. It was the close proximity of the suicides to each other during the most recent eight-month period that prompted concern within the agency. In order to independently assess current practices, as well as offer any appropriate recommendations to jail suicide prevention policies and procedures within the Rappahannock Regional Jail, Superintendent Larry Hamilton and his executive jail staff decided to seek the assistance of an outside consultant. Through the technical and financial assistance of the National Institute of Corrections - Jails Division, the services of this writer were offered to, and selected by, the Rappahannock Regional Jail.
It should be noted that 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 Superintendent Hamilton who, along with his executive jail staff, were committed to determining what steps, if any, were necessary to improve suicide prevention practices within the Rappahannock Regional Jail.
Built in 2000, the Rappahannock Regional Jail (RRJ) has a 656-bed capacity and serves four jurisdictions -- the City of Fredericksburg, King George County, Spotsylvania County, and Stafford County. The agency also has a contact with the U.S. Immigration and Naturalization Service for approximately 25 to 30 beds. On July 9, 2003, the population was 833 inmates, and the average daily population was 842 inmates. In addition, there are approximately 10,000 jail admissions each year, or slightly more than 27 per day.
As shown by Table 1, the Rappahannock Regional Jail experienced three inmate suicides during the most recent five-year period of 1999 through July 2003, all of which occurred between October 2002 and June 2003. Thus, although the recent rash of suicides should be (and has been) of great concern to jail officials, and has resulted in a suicide rate that is substantially higher than the average throughout the country, prior to October 2002, the Rappahannock Regional Jail had not experienced an inmate suicide in recent memory.
TABLE 1
INMATE SUICIDES and AVERAGE DAILY POPULATION
WITHIN RAPPAHANNOCK REGIONAL JAIL
1999 THRU 2003
Year ADP* Suicides Rate
1999 267** 0 0
2000 578 0 0
2001 707 0 0
2002 786 1 127.2
2003 (thru July) 856 2 233.6 ________________________________________________________________________ 1999-July 2003 3,194 3 93.9
_______________________
* Data provided by the Rappahannock Regional Jail
**Data from old jail
B. FINDINGS AND RECOMMENDATIONS
While on-site in Stafford, Virginia on July 8 and 9, 2003, this writer toured the Rappahannock Regional Jail, as well as met with and/or interviewed numerous correctional, medical, and mental health staff. In addition, this writer met initially with Superintendent Hamilton and Captain Scott Baird, Director of Security and Confinement on the morning of July 8, as well as for a longer debriefing session in the late afternoon of July 9.
Finally, this writer reviewed numerous documents relating to the assessment of jail suicide prevention practices within the Rappahannock Regional Jail, including, but not limited to, the following information: 1) policy and procedures relating to suicide prevention; 2) various suicide prevention training material; 3) health care and security case files for several inmates that had recently been placed on suicide precautions; and 4) health care and security case files on the three recent inmate suicides.
Detailed below is this writer's assessment of suicide prevention practices within the Rappahannock Regional Jail. It is formatted according to this writer's eight (8) critical components of a suicide prevention policy: staff training, identification/screening, communication, housing, levels of supervision, intervention, reporting, and follow-up/mortality review. This protocol was developed in accordance with both Standard 3-ALDF-4E-34 of the American Correctional Association's Standards for Adult Local Detention Facilities (1991) and Standard J-G-05 of the National Commission on Correctional Health Care's Standards for Health Services in Jails (2003). Where applicable, reference is also made to the Virginia Board of Corrections' Minimum Standards for Jails and Lockups and Compliance Documentation for Local Jails and Lockups (2002). Where indicated, recommendations are also provided.
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 why jail and prison environments are conducive to suicidal behavior, potential predisposing factors to suicide, high-risk suicide periods, warning signs and symptoms, and components of the agency's suicide prevention program.
The key to any successful suicide prevention program is properly trained correctional staff, who are the backbone of any jail facility. Very few suicides are actually prevented by mental health, medical or other professional staff. Because suicides usually are attempted in inmate housing units, often during late evening hours or early morning hours, they are generally outside the purview of program staff. Therefore, these incidents must be thwarted by correctional officers who have been trained in suicide prevention and have an intuitive sense regarding the inmates under their care. Simply stated, because correctional officers are generally the only staff in the jail 24 hours per day, they form the front line of defense in suicide prevention. Staff cannot detect, make an assessment, nor prevent a suicide for which they have no training.
Both the American Correctional Association (ACA) and National Commission on Correctional Health Care (NCCHC) standards stress the importance of on-going training as a critical component to any suicide prevention program. ACA Standard 3-ALDF-1D-12 requires that all correctional staff receive annual training in the "signs of suicide risk" and "suicide precautions;" while Standard 3-ALDF-4E-34 requires that staff be trained in the implementation of the suicide prevention program. As stressed in NCCHC Standard J-G-05 -- "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."
FINDINGS: Upon employment with the Rappahannock Regional Jail (RRJ), all correctional staff are required to attend and complete a 10-week, 376-hour jail officer training at the Rappahannock Regional Criminal Justice Academy. This basic training program contains an eight-hour block on Suicide Prevention, and its curriculum was reviewed and found to be based in large part upon the 1995 training manual previously co-authored by this writer. The provision of an eight-hour block devoted to jail suicide prevention exceeds the training standards for the majority of states throughout the country.
In regard to annual training, although the state mandates 24 hours of instruction every two years, RRJ has developed and maintained a 24-hour annual in-service training program. Although the state requires that correctional officers receive cardiopulmonary resuscitation (CPR) training every two years, RRJ exceeds that standard by requiring its officers to receive a four-block of CPR training every year. In 2000, the RJJ offered a four-block of suicide prevention training as part of its annual in-service training program. It appeared that this program was a condensed version of the eight-hour basic training academy course. However, suicide prevention training was not offered to correctional staff during either 2001 or 2002. In September 2003, RRJ will again offered an eight-hour suicide prevention seminar to all of its correctional staff, as well as its medical personnel. The training will be offered over a four-day period and is mandatory for all staff. The training curriculum ("Suicide Recognition and Prevention in Jails and Lockups") was reviewed and found to be based in large part upon the 1995 training manual previously co-authored by this writer.
RECOMMENDATIONS: Only a few recommendations are offered. First, it is strongly recommended that RRJ continue to offer a mandatory suicide prevention training workshop on an annual basis. Although national standards do not specify course duration, it would be this writer's opinion that a workshop of between two to four hours duration is acceptable. The workshop should include, but not be limited to, discussion on why jail environments are conducive to suicidal behavior, potential predisposing factors to suicide, high-risk suicide periods, warning signs and symptoms, critical components of RRJ's suicide prevention policies and procedures, intervention following a suicide attempt, critical incident stress debriefing, and liability issues. It is strongly recommended that the annual training program also include general discussion on the three recent inmate suicides. Analysis of these incidents would not only be instructional, but beneficial to future prevention efforts.
Second, it is strongly recommended that all health care personnel (i.e., medical and mental health staff) be required to complete the recommended annual suicide prevention training workshop.
In creating a permanent annual in-service training program, RRJ officials are encouraged to utilize this writer's previously referenced training curriculum, as well as Jail Suicide/Mental Health Update newsletter. The superintendent, director of security, and mental health clinician have all been placed on the mailing list to receive the Update newsletter, a quarterly publication available at no charge and devoted to suicide prevention and mental health services within correctional facilities. An additional resource would be the New York State, Office of Mental Health (NYSOMH)'s Suicide Prevention and Crisis Intervention in County Jails and Police Lockups - Basic Program Trainer's Manual (2000). Further information regarding that training manual (and accompanying videotapes) can be obtained by the NYSOMH, Bureau of Forensic Services, 44 Holland Avenue, Albany, New York 12229, (518/474-7219), http://omh.state.ny.us/omhweb/forensic/suicide.htm
2) Identification/Screening: 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 treatment/ 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 confinement; and arresting/
transporting officer(s)' views of detainee's suicide risk. Must include procedures for referral to mental health and/or medical personnel.
Identification/screening is also critical to a jail system's suicide prevention efforts. An inmate can attempt suicide at any point during incarceration -- beginning immediately following intake and continuing through a stressful aspect of confinement. Although there is disagreement within the psychiatric and medical communities as to which factors are most predictive of suicide in general, research in the area of jail and prison suicides has identified a number of characteristics that are strongly related to suicide, including: intoxication, emotional state, family history of suicide, recent significant loss, limited prior incarceration, lack of social support system, psychiatric history, and various "stressors of confinement." Most importantly, prior research has consistently reported that at least two 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 those who have never made an attempt. 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.
Both the ACA and NCCHC standards address the issue, with the latter stating -- "Identification: The receiving screening form contains observation and interview items related to the inmate's potential suicide risk...Evaluation: An evaluation, conducted by a qualified mental health professional, designates the individual's level of suicide risk, level of supervision needed, and need for transfer to an inpatient mental health facility or program."
FINDINGS: All detainees receive basic initial screening (via an "Intake Screening Form") by an intake officer upon entry into the RRJ. The computerized form includes the following inquiry regarding suicide risk:
o Suicidal threats
o Signs of extreme nervousness/restlessness
o Signs of extreme depression
o Withdrawn/non-communicative
The intake form is then forwarded to medical staff for review.
Following the initial screening process, each detainee is seen by classification staff who complete an "Initial Classification Assessment" form. The assessment form contains two questions regarding suicide risk:
o Have you ever had any previous suicide attempts?
o Do you feel like you may want to harm yourself now?
Further, medical staff are required to complete a "Health and Physical Assessment" within 15 days of an inmate's confinement. The form includes inquiry of psychiatric history, but not suicide risk.
Although RRJ's current practices for the identification of suicide risk conform with Virginia Board of Corrections' jail standards, this writer found several problems that impede the identification of suicidal inmates during the early stages of confinement within the facility.
First, the current Intake Screening Form does not contain sufficient inquiry regarding potential suicide risk (e.g., it is not formatted in a question format, thereby relying on observation only), nor has a "Disposition" section (e.g., general population, infirmary, suicide precautions, mental health, etc.) for referral. In addition, there is no inquiry directed at the arresting/transporting officer regarding their observation of any medical, mental health, or suicide risk by the detainee.
Second, there is currently no automatic mechanism utilized by either the intake officer or classification staff to determine whether the detainee/inmate was a suicide risk during prior RRJ confinement. Although the information regarding prior suicide risk within the RRJ should be available in both the inmate's classification and medical files, the information is not always routinely accessed.
Third, inmates do not receive a mental health assessment within 14 days of admission into the RRJ. In fact, inmates are only assessed by mental health staff upon referral. Although this practice is not a violation of Virginia Board of Corrections' jail standards, it is contrary to NCCHC standards. It should also be noted that although medical staff are required to complete a Health and Physical Assessment, the form does not include sufficient inquiry regarding both mental illness and suicide risk, and would not qualify as a mental health assessment.
RECOMMENDATIONS: Several recommendations are offered. First, it is strongly recommended that RRJ officials implement a new procedure that requires the arresting and/or transporting officer to notify intake staff at the facility as to whether they have any information (e.g. from observed behavior during arrest/transport, documentation from the sending agency/facility, family member, etc.) that indicates detainee is a medical, mental health or suicide risk upon entry into the facility. To assist in the notification process, a sample "Arresting/Transporting Officer Questionnaire" is enclosed in Appendix A for consideration. This or a similar form should always be completed by the transporting/arresting officer prior to leaving the RRJ.
Second, it is strongly recommended that the current Intake Screening Form be revised in order to allow for further inquiry of potentially suicidal behavior. The revised form should be question-formatted and include the following lines of inquiry:
o Was inmate a medical, mental health or suicide risk during any prior RRJ confinement?
o Have you ever attempted suicide? If Yes, When? Why? How?
o Have you ever considered suicide? If Yes, When? Why?
o Are you now or have you ever been treated for mental health or emotional problems? If Yes, When?
o Have you recently experienced a significant loss (relationship, death of family member/close friend, job. etc.)? If Yes,
explain.
o Has a family member/close friend ever attempted or committed suicide? If Yes, explain.
o Do you feel there is nothing to look forward to in the immediate future (inmate expressing hopelessness and/ or helplessness)? If Yes, explain.
o Are you thinking of hurting and/or killing yourself? If Yes,
explain.
Attached for consideration in Appendix B are two sample intake screening forms, one of which was previously developed by this writer.
Although inquiry and verification of prior suicide risk within the RRJ at intake and/or classification will require either development of a new screen and/or adaptation of a current screen in the facility's Criminal Justice Management System (CJMS), access to such information will be critical to assessing current risk and reducing potential liability for the agency. This writer was informed that the "Booking Information Screen" on the CJMS contains an "alert" box for "incompatible" inmates that possibly could be adapted to also contain an alert for prior mental illness and/or suicide risk within the RRJ. Once revised, the following recommendations are offered:
o The intake officer should always review the CJMS to verify whether the detainee was previously confined in the RRJ and had any history of mental illness and/or suicidal behavior during a prior confinement;
o Classification deputies should always review a detainee's prior classification/housing record in the CJMS to determine if they had a prior history of mental illness and/or suicidal behavior within the RRJ; and
o Regardless of the detainee's behavior or answers given during the intake screening and classification interviews, an immediate referral to mental health staff should always be initiated based on documentation reflecting possible mental illness and/or suicidal behavior during an inmate's prior confinement within the RRJ.
Third, consistent with J-E-05 (Mental Health Screening and Evaluation) of the NCCHC standards, it is strongly recommended that mental health assessments be completed on all inmates within 14 days of admission into the RRJ. As recommended by NCCHC, the assessments can be completed by either qualified mental health professionals or "health care professionals who have received instruction and supervision in identifying and interacting with individuals in need of mental health services."
Fourth, in assessing an inmate's risk of suicide, mental health staff might want to develop a formalized assessment form that can be easily accessed in the inmate's integrated medical/mental health file. An example of such a form ("Suicide Consultation Sheet") is attached as Appendix C.
Fifth, various RRJ policies currently state that medical staff will conduct intake screening of detainees as they are processed into the facility. Given the fact that the intake screening process is conducted by correctional (not medical) personnel, it is strongly recommended that RRJ policies be revised to reflect such practice.
3) Communication: Procedures that enhance communication at three levels: 1) between the transporting officer(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 transporting officer and correctional staff; 2) between and among staff (including mental health 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. As aptly stated by one clinician:
The key to an effective team approach in suicide prevention and crisis intervention is found in throwing off the cloaks of territoriality and embracing a mutual respect for the detention officer's and mental health clinician's professional abilities, responsibilities and limitations. All of us, regardless of professional affiliation, need to make a dedicated commitment to come forward and acknowledge that suicide prevention and related mental health services are only effective when delivered by professionals acting in unison with each other. Just as the security officer alone can not ensure the safety and security of the jail facility, neither can the mental health clinician alone ensure the safety and emotional well-being of the individual inmate.
FINDINGS: Overall, this writer found that RRJ had a very effective system of communication for the identification and management of suicidal inmates. This writer also sensed that correctional and health care staff have a good working relationship. In fact, as witnessed by this writer, the superintendent, director of security, and health care personnel meet on a regular basis to discuss inmate health care, including review of inmates on suicide precautions. In addition, medical and mental health personnel share and integrated health care file, thereby allowing for ready access to mutual information regarding an inmate's mental health and suicide risk status. Further, mental health staff utilize a "Suicide Precaution Health Consult Form" and "Special Housing Requirements Form" to communicate the management needs of inmates placed on suicide precautions. Both forms are color-coded yellow to allow for easy identification in the inmate's health care file.
Finally, the RRJ utilizes an Institutional Classification Committee (ICC) to assess the continued need for an inmate's placement on various segregation statuses. The inmate's overall health care is also assessed. The ICC (comprising a classification officer, nurse, security staff, and correctional counselor) meet with each inmate on segregation status every 15 days.
RECOMMENDATION: Only one recommendation is offered. Given the potential for deterioration of an inmate's mental health through prolonged segregation status, it is strongly recommended that the Institutional Classification Committee be expanded to include a member of the mental health staff.
4) Housing: Isolation should be avoided. Whenever possible, suicidal inmates should be housed in general population, mental health unit, or medical infirmary, located in close proximity to staff. Inmates should be housed in suicide-resistant, protrusion-free cells. Removal of an inmate's clothing (excluding belts and shoelaces), as well as use of medical restraints (e.g., straitjackets, leather straps, restraint chairs or boards, 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.
In determining the most appropriate location to house a suicidal inmate, there is often the tendency for correctional officials in general to physically isolate and restrain the individual. These responses may be more convenient for staff, but they are 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 difficult issue. The result, of course, will be the assignment of the suicidal inmate to a housing unit commensurate with his security level. Within a correctional system, this assignment might be a "special management unit." However, to every extent possible, such inmates should be housed in suicide-resistant, protrusion-free cells. Further, removal of an inmate's clothing (excluding belts and shoelaces), as well as the use of medical restraints (e.g., straitjackets, leather straps, restraint chairs or boards, 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: Overall, the RRJ offers safe housing for those inmates identified as being potentially suicidal. The facility primarily utilizes four Crisis Cells located in the Infirmary area for suicide precautions. Should those cells be occupied, selected cells in Special Placement (SP) Units 1 through 3 are utilized. Inspection of both cell areas found that they were as "suicide resistant" as possible, i.e., not containing any obvious protrusions that would be conducive to a suicide attempt by hanging. In addition, all suicidal inmates are required to remove their clothing and issued "safety smocks." It should also be noted that none of the recent three inmate suicides occurred in the above described housing areas.
RECOMMENDATIONS: A few recommendations are offered. First, the current RRJ policy on suicide prevention (3.7.4) states that the safety smock "may be used" for the suicidal inmates, and that "inmates who have suicidal tendencies and are not an immediate threat to themselves may be required….to wear one." There are several inconsistencies to the wording of this policy that needs to be corrected. This writer found, for example, that the safety smock is not selectively used; rather it is issued for all inmates placed on suicide precautions. In addition, the rationale for utilizing the safety smock should be because the inmate is assessed as being at "high risk" for suicide, and not because they are viewed as "not an immediate threat." As such, it is strongly recommended that the current suicide prevention policy (3.7.4) be revised to emphasize greater flexibility in determining the issuance of safety smocks. The removal of an inmate's clothing and issuing of a safety smock should be avoided whenever possible, and only utilized as a last resort on a case-by-case basis for periods in which the inmate is either physically engaging in self-destructive behavior or is assessed as being an immediate threat for self-harm.
Second, given the fact that the four Crisis Cells lack toilet facilities, it is strongly recommended that inmates held in those cells be assessed on a daily basis by mental health staff and only remain in those cells for as long as is clinically necessary.
Third, several patient rooms (non-crisis cells) in the Infirmary area contain telephone boxes located on the wall. Because telephone cords may create a safety hazard to suicidal inmates, it is strongly recommended that these rooms not be utilized to house a suicidal inmate. If temporarily used to allow a suicidal inmate to place a telephone call, the room should be under constant supervision by staff.
5) Levels of Supervision: 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. This inmate should be observed by staff at staggered intervals not to exceed every 15 minutes. Constant Observation is reserved for the inmate who is actively suicidal, either by threatening or engaging in the act of suicide. This inmate should be observed by a staff member on a continuous, uninterrupted basis. In some jurisdictions, an intermediate level of supervision is utilized with required observation at staggered intervals that do not exceed every 5 minutes. Other supervision aids (e.g., closed circuit television, inmate companions/watchers, etc.) can be utilized as a supplement to, but never as a substitute for, these observation levels.
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. Medical experts warn that brain damage from strangulation can occur within four minutes, with death often resulting within five to six minutes. In inmate suicide attempts, the promptness of the response is often driven by the level of supervision afforded the inmate. Both the ACA and NCCHC standards address levels of supervision, although the degree of specificity varies. ACA Standard 3-ALDF-3D-08 vaguely requires that "suicidal inmates are under continuous observation," while NCCHC Standard J-G-05 requires observation ranging from "continuous monitoring" to physical checks "every 15 minutes or more frequently if necessary."
FINDINGS: First, per the jail standards of the Virginia Board of Corrections, RRJ adheres to a policy that requires supervision of all inmates "a minimum of twice per hour at random intervals between inspections." This practice should result in cell checks at approximate 30-minute intervals. However, this writer observed from talking with various correctional staff that cell checks are not always performed at approximate 30-minute intervals; rather they are simply performed twice an hour (e.g., once after 20 minutes, then again 40 minutes later). In fact, in reviewing the investigative reports on the recent inmate suicides, this writer found that two of the victims had been unobserved by correctional staff in excess of 30 minutes.
Second, although the RRJ suicide prevention policy (3.7.4) states that suicidal inmates will be placed on a "special watch" to include one of the following observation levels: "routine check with special attention and notation of specific behavior patterns," "15-minute watch," and "constant supervision"; this writer found that there appeared to be only one level of observation available for suicidal inmates, i.e. 15-minute watch. Although this level of observation would be sufficient for most inmates placed on suicide precautions and that are at low risk for suicide, observation at 15-minute intervals is grossly inadequate for acutely suicidal inmates. In addition, the current policy does not define the behavior that necessitates a specific level of observation. Finally, the required observation of a suicidal inmate is currently documented in the housing unit log at specified intervals rather than on an individual observation form for each inmate.
Third, contrary to NCCHC standards and standard correctional practice, mental health staff do not assess all inmates on suicide precautions on a daily basis.
Fourth, although the Institutional Classification Committee assesses inmates in segregation every 15 days, health care personnel (either medical or mental health staff) do not make regular rounds of administrative segregation and disciplinary confinement housing units. Although this practice does not violate jail standards of the Virginia Board of Corrections, it is contrary to both ACA and NCCHC standards which require rounds by health care personnel at least three times per week.
Fifth, mental health staff do not conduct regularly scheduled follow-up assessments of inmates discharged from suicide precautions and returned to their respective housing units. This writer was informed that such follow-up assessments are conducted on a case-by-case basis. It would be this writer's opinion that the ability to conduct regular follow-up assessments with inmates discharged from suicide precautions is a critical component of a jail system's suicide prevention program. Many inmates that commit suicide have histories of serious mental illness and prior suicidal behavior. Providing a continuity of care for these inmates is critical to suicide prevention.
RECOMMENDATIONS: Several recommendations are offered to not only strengthen the observation protocols for suicidal inmates, but also increase contact between health care personnel and the inmate population. First, although the RRJ appears to be compliance with the state requirements for inmate supervision, it is strongly recommended that correctional staff adhere to a practice of conducting cell checks at approximate 30-minute intervals.
Second, it is strongly recommended that the RRJ suicide prevention policy (3.7.4) be revised to delete reference to "routine check with special attention and notation of specific behavior patterns." The unspecified nature of this observation level could potentially become subject to confusion and misinterpretation. In addition, it is strongly recommended that the policy be further revised to include the following two specific levels of observation:
Close Observation: Reserved for the inmate who is not actively suicidal, but expresses suicidal ideation and/or has a recent prior history of self-destructive behavior. This inmate should be observed by staff at staggered intervals not to exceed every 15 minutes, and the observation should be documented as it occurs.
Constant Observation: Reserved for the inmate who is actively suicidal, either by threatening or engaging in the act of suicide. This inmate should be observed by a staff member on a continuous, uninterrupted basis. The observation should be documented at 15-minute intervals.
In discussing the issue of multiple options for observing suicidal inmates with mental health staff, this writer was informed that such a flexible policy would allow them to tailor the level of observation to the level of suicide risk (e.g., high vs. low). Similar to the issue of clothing, possessions, and other basic amenities as discussed above, observation levels should be commensurate with the inmate's behavior and not the availability of staff.
Third, it is strongly recommended that the observation of inmates placed on suicide precautions should be documented on an observation form for each inmate, not in the housing unit log. Copies of each completed form should be forwarded to mental health staff for review. A sample "Suicide Watch Observation Sheet" previously developed by this writer is enclosed for consideration in Appendix D.
Fourth, it is strongly recommended that mental health staff assess all inmates on suicide precautions on a daily basis. In addition, mental health, medical, and correctional staff should confer on a daily basis regarding issues pertaining to the inmate's level of observation, clothing and possessions allowed, medication compliance, etc.
Fifth, consistent with national standards, health care personnel (either medical or mental health staff) should make regularly scheduled rounds of "special housing units" (administrative segregation, disciplinary confinement, classification, protective custody, etc.) three times per week. These rounds should be documented in each housing unit log.
Sixth, 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 the RRJ. Although there is not any nationally acceptable schedule for follow-up, a suggested assessment schedule following discharge from suicide precautions might be: daily for 5 days, once a week for 2 weeks, and then once a month until release from the facility.
6) Intervention: At a minimum, 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 (CPR); 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 first aid and/or CPR; 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).
Following a suicide attempt, the degree and promptness of intervention provided by staff often foretells whether the victim will survive. Although both the ACA and NCCHC standards address the issue of intervention, neither are elaborative in offering specific protocols. For example, ACA Standard 3-ALDF-4E-24 requires that -- "personnel are trained to respond to health-related situations within a four-minute response time. The training program...includes the following: recognition of signs and symptoms, and knowledge of action required in potential emergency situations; administration of first aid and cardiopulmonary resuscitation (CPR)..." NCCHC Standard J-G-05 states -- "Intervention: There are procedures addressing how to handle a suicide in progress, including appropriate first-aid measures."
FINDINGS: This writer found that the RRJ had very good practices regarding intervention measures following discovery of a suicide attempt. First, consistent with both ACA and NCCHC standards, all correctional staff are required to be certified in both first aid and CPR. In fact, as previously discussed, the frequency of first aid and CPR training of correctional staff exceeds the standards of the Virginia Board of Corrections. In reviewing the investigative reports on the three recent inmate suicides, this writer found that both correctional and health care personnel promptly initiated life-saving measures (including CPR) on all of the victims.
Second, the facility had five automated external defibrillators (AEDs) -- one located in the Infirmary area with the remaining units distributed throughout the housing areas. In responding to emergencies, medical staff are required to take an emergency cart containing the AED and portable oxygen tank. The purchase and utilization of AEDs (not required by jail standards of the Virginia Board of Corrections) and is very commendable.
Third, although this writer observed first aid kits in most housing units, the kits did not contain "rescue tools" to cut a noose from a hanging victim.
RECOMMENDATIONS: This writer would offer only two minor recommendations. First, it is strongly recommended that health care staff should ensure that the emergency cart is fully stocked and inspected on a regular basis. Second, it is strongly recommended that RRJ officials purchase "Emergency Rescue Tools" that should be placed in first aid kits (or other secure locations) within each housing unit. Emergency Rescue Tools are now commonly utilized in correctional facilities throughout the country. With their hooked shape, the tools allow for rapid insertion between the ligature device and the skin, with no risk of cutting the victim. One particular inexpensive knife (the "Addis Wonder Knife") has a stainless steel blade that can quickly cut through all fibrous material found in an inmate's cell, including blankets, sheets, clothing, belts, and shoelaces. Because the blade is located inside the frame of the tool, it can not be utilized as a life-threatening weapon in the hands of an inmate. (For more information on a variety of rescue tools, see Appendix E).
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.
FINDING: Following case file reviews of all three recent inmate suicides, this writer found that reporting procedures seemed to have been appropriately followed.
RECOMMENDATIONS: None
8) Follow-up/Mortality Review: Every completed suicide, as well as serious suicide attempt (i.e., requiring hospitalization), should be examined by a mortality review. (If resources permit, clinical review through a psychological autopsy is also recommended.) The mortality 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; and 5) 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 mortality review should be two-fold: What happened in the case under review and what can be learned to help prevent future incidents? To be successful, the mortality review team must be multidisciplinary and include representatives of both line and management level staff from the correctional, medical and mental health divisions.
FINDINGS: First, although the RRJ does not currently have a formalized multidisciplinary mortality review process for inmates suicides, there are a few examples by which the agency has attempted to seek corrective action as a result of the recent suicides. In addition to the internal affairs investigations conducted following each death, the jail administration has met informally with both medical and mental health staff regarding the deaths. Further, RRJ officials recently sought the assistance of this writer (through the technical and financial support of the National Institute of Corrections - Jails Division) to conduct an independent assessment of suicide prevention practices.
Second, in regard to critical incident stress debriefing (CISD), it would appear that although the RRJ had a CISD policy (3.2.12), this writer observed that several correctional staff appeared unaware of the availability for such assistance following a traumatic event within the facility.
RECOMMENDATIONS: This writer would offer several recommendations. First, it is strongly recommended that the RRJ institute of formalized mortality review process following an inmate suicide (or other death) and/or serious suicide attempt requiring hospitalization. To ensure that the process is comprehensive, a multidisciplinary committee comprising correctional, medical, and mental health personnel (including both line and management staff) should be formed. Exclusion of one or more disciplines will severely jeopardize the integrity of the mortality review. Attached as Appendix F is a sample "Mortality Review of Inmate Suicides" outline previously developed by this writer.
Second, to ensure that all staff are aware of the availability of CISD, it is strongly recommended that the subject be thoroughly discussed during annual in-service training at the facility.
C. ADDITIONAL ISSUES
Although the issue of staffing and personnel is well outside the scope of this short-term technical assistance, this writer would be remiss in not stating that the Rappahannock Regional Jail is in dire and immediate need of additional mental health personnel. Basic mental health services, including, but not limited to, daily assessment of suicidal inmates, mental health assessments on all inmates within 14 days, regular rounds of special housing areas (and membership in the Institutional Classification Committee), and caseload management and regular follow-up of mentally ill inmates and those previously under suicide precautions are currently not being provided because there is currently only one full-time mental health clinician assigned to the facility by the Rappahannock Area Community Services Board.
The presence of only one mental health staff has also resulted in a troubling practice -- the large backlog of inmate referrals for the mental health services. This writer was informed that the lone full-time clinician triages referrals into three basic categories: emergency, routine and follow-up. According to the clinician, although most emergency referrals are responded to almost immediately and at least during the same day of the referral, there are occasions in which these referrals are not responded to within 24 hours; it often takes several weeks to respond to routine referrals; and follow-up referrals are responded to on a case-by-case basis. It would be this writer's opinion that there should never be an occasion by which a triaged emergency referral is not responded to within 24 hours.
Further, national correctional standards [including those of the ACA, NCCHC, and American Psychiatric Association (APA) ] require that decisions regarding the administration of psychotropic medication is made only following a comprehensive evaluation. For example, according to ACA standard 3-ALDF-4E-18, "Psychotropic drugs, such as anti-psychotics, anti-depressants, and drugs requiring parenteral administration, are prescribed only by a physician or authorized health provider by agreement with the physician, and then only following a physical examination of the inmate by the health provider." NCCHC standard J-D-02 states that the "responsible physician determines prescriptive practices in the facility." APA standards state that "psychotropic medication should be prescribed and monitored by a psychiatrist…procedures should be developed and monitored by a psychiatrist to ensure that psychotropic medications are distributed by qualified medical personnel."
Within the RRJ, this writer both observed and was informed that the issue of psychotropic medication was almost exclusively controlled by the mental health clinician, not a psychiatrist. In fact, there were no on-site services of a psychiatrist at the facility. Instead, the mental health clinician acted as a "gatekeeper" in determining which inmates would be assessed by a psychiatrist from the Rappahannock Area Community Services Board. In addition, it appeared that decisions regarding psychotropic medication were made based largely upon the clinician's opinion as to whether the inmate was "drug seeking" to satisfy an addiction, and without a formal mental health evaluation. Those inmates deemed in need of a psychiatric assessment would be personally escorted by the mental health clinician (with a security officer) to the psychiatrist's office. When asked why he would utilize valuable time in personally escorting an inmate to the psychiatrist's office (instead of the doctor periodically coming to the RRJ), the clinician informed this writer that there would be a tremendous increase in inmate referrals for psychotropic medication if inmates knew that the psychiatrist had regular office hours at the RRJ.
Although very appropriate for a mental health clinician to act as a "gatekeeper" for the psychiatrist, there is often a fine line between screening out "drug seeking" and other perceived manipulative behavior and limiting or even denying requested psychiatric services. For example, it has been estimated that approximately 16 percent of all jail inmates throughout the country have some form of mental illness, and many of these individuals are current taking psychotropic medication. Within the RRJ, this writer was informed that approximately 7 percent (60 of 833) of inmates were receiving psychotropic medication. As such, the number of RRJ inmates receiving psychotropic medication appeared low and, coupled with the dubious notion that presence of a psychiatrist at the facility would lead to a dramatic increase in referrals for psychotropic medication, suggests that further inquiry is warranted.
At a minimum, it is strongly recommended that RRJ officials meet with both the mental health clinician and officials from the Rappahannock Area Community Services Board to discuss the above issues, including the need for additional mental health personnel to provide basic mental health and suicide prevention services (as recommended above), clinical supervision of the mental health clinician, quality assurance medical chart review, developing of a protocol for assessing an inmate's need for psychotropic medication, and feasibility of regularly scheduled on-site hours by a psychiatrist.
D. CONCLUSION
It is hoped that the short-term technical assistance provided by this writer, as well as the recommendations contained within this report, will be of assistance to the Rappahannock Regional Jail. This writer met numerous correctional, medical, and mental health personnel who were genuinely concerned about inmate suicide and committed to taking whatever actions were necessary to reduce the opportunity for such a tragedy in the future. And although this report contains several recommendations for improvements in suicide prevention practices, the corrective action offered should not be interpreted as having a direct causal link to any of the recent inmate suicides.
In conclusion, this writer would be remiss by not extending sincere appreciation to Superintendent Larry Hamilton and Captain Scott Baird. Without the total cooperation and assistance from these individuals, as well as all those correctional and health care personnel who were interviewed, this writer would not have been able to complete this assessment.
Respectfully Submitted By:
Lindsay M. Hayes
August 2, 2003
APPENDICES
A) Arresting/Transporting Officer Questionnaire
B) Sample Intake Screening Forms
C) Suicide Consultation Sheet
D) Suicide Watch Observation Sheet
E) Emergency Rescue Tools
F) Mortality Review of Inmate Suicides