Federal prisons have for years been plagued by "a multitude of operational failures" that have resulted in inmates dying, many of them by suicide, a federal watchdog has found.

A report by the inspector general for the U.S. Department of Justice, published Thursday, found that the Federal Bureau of Prisons, or BOP, failed to mitigate the risk of death among prisoners, and that numerous internal challenges and violations of policies have resulted in inmates taking their own lives.

More than half of the 344 people who died in federal custody during an eight-year period beginning in fiscal year 2014 killed themselves. Homicide was the second-highest cause of death. The overall number of deaths peaked at 57 in 2021, the same year which also had the highest number of suicides — 31 — over the same period, according to the report.

"We identified several operational and managerial deficiencies, which created unsafe conditions prior to and at the time of a number of these deaths, that the BOP must address," the report says.

The report, which looked at four categories of deaths — suicides, homicides, accidental deaths including drug overdose, and deaths resulting from unknown factors — concluded that inadequate staff response to inmate emergencies and failure to monitor inmates at risk for suicide contributed to some of those deaths.

In addition, long-standing operational issues such as contraband, security camera coverage and understaffing further limited BOP's ability to control the risk of death among inmates, according to the report.

"Recent high-profile inmate deaths at federal prisons have raised concerns about operational and management challenges at the Federal Bureau of Prisons," Michael Horowitz, the DOJ inspector general, said in a video statement accompanying the report. "It's critical that the BOP address these challenges, so it can operate safe and humane facilities and protect inmates in its custody and care."

Incident documentation probed by the inspector general showed that prison personnel failed to identify inmates at risk of committing suicide and even sidestepped BOP's own recommendations.

For instance, although the BOP has recommended against single-celling inmates, noting it increases the risks of inmate suicide, more than half of the inmates who died by suicide during the eight-year period were confined alone. Insufficient inmate counts and lack of responsiveness or preparation by prison employees also contributed to the suicides, the report says.
About 46% of people who died by suicide did so by hanging, and 20% took their lives by overdosing on drugs.

"Under these conditions, inmates were able to advance their suicidal ideations and ultimately died by suicide," the report said. "To effectively mitigate the risk of death by suicide among inmates in its custody, the BOP must address the recurring issues we identified."

Overall, the report found "significant shortcomings," including a "lack of urgency" in the way prison staff responded to nearly half of the emergencies that ended in death. Many of the deaths that occurred under accidental or otherwise unknown circumstances involved drug overdoses. 

Drugs and weapons smuggled into prisons were linked to nearly one-third of the inmate deaths that occurred during the investigated period. In numerous cases, inoperable security cameras or poor footage could not capture violence inside prisons. In addition, staffing shortages and ineffective personnel discipline are continuing to pose a risk to inmates, the report says.

The highest number of deaths, 17, was reported at U.S. Penitentiary Atlanta — which, as of March 2018, housed nearly 1,900 people — followed by U.S. Penitentiary Terre Haute, Indiana, and U.S. Penitentiary Hazelton, West Virginia.

Last July, an 18-month investigation into the Special Management Unit in the U.S. penitentiary in Thomson, Illinois, found that BOP failed to punish administrators for what have been described as "extreme physical and psychological abuse" at the hands of staffers and fellow inmates.

The investigation was conducted by the nonprofit Washington Lawyers' Committee for Civil Rights and Urban Affairs, and lawyers from Latham & Watkins LLP, Uptown People's Law Center and Levy Firestone Muse LLP.

Carl Bailey, a spokesperson for the BOP, told Law360 in an email Friday that the agency has "already taken substantial steps" to mitigate the risk of death among prisoners and said the inspector general's findings provide an opportunity to make improvements.

"Our priority is addressing the unique health challenges, including mental health, faced by individuals in custody, particularly those with a higher incidence of substance use disorders," Bailey said. "We are committed to suicide prevention, substance use disorder treatment, and combating contraband. Our multidisciplinary approach includes evidence-based treatments, comprehensive employee training, and continuous efforts to enhance screening methods."

The BOP could not immediately provide more recent data on inmate deaths than those described in the report.

U.S. Sen. Dick Durbin, D-Ill., who chairs the Senate Judiciary Committee, announced that the committee will hold a hearing on Feb. 28 to ask officials about the deaths in BOP custody and the concerns highlighted in the report. Horowitz and BOP Director Colette Peters are expected to testify at the hearing.

"It is deeply disturbing that today's report found that the majority of BOP's non-medical deaths in custody could have been prevented or mitigated by greater compliance with BOP policy, better staffing, and increased mental health and substance abuse treatment," Durbin said following the report's publication on Thursday. "Accountability across the Bureau is necessary and long overdue."

--Editing by Lakshna Mehta.