U.S. Department of Justice
National Institute of Corrections

U.S. Department of Justice
National Institute of Corrections
320 First Street, NW
Washington, DC 20534

Morris L. Thigpen
Director
Thomas J. Beauclair
Deputy Director
Virginia A. Hutchinson
Chief, Jails Division
Fran Zandi
Program Manager

National Institute of Corrections
www.nicic.gov

Lindsay M. Hayes, Project Director

National Center on Institutions and Alternatives

April 2010
NIC Accession Number 024308

This document was prepared under cooperative agreement number 06J47GJM0 from the
National Institute of Corrections, U.S. Department of Justice. Points of view or opinions stated
in this document are those of the author and do not necessarily represent the official position
or policies of the U.S. Department of Justice.

Contents

Foreword .......................................................................................................... vii

Acknowledgments ..............................................................................................ix

Executive Summary............................................................................................xi

Chapter 1. Introduction ...................................................................................... 1

Prior Jail Suicide Research.................................................................................... 2

A Word About Suicide Victim Profiles .................................................................... 3

Death in Custody Reporting Act of 2000................................................................ 4


Chapter 2. National Study of Jail Suicides: 20 Years Later ................................... 7

Methodology: Phase 1......................................................................................... 7

Methodology: Phase 2......................................................................................... 9


Chapter 3. Demographic Findings of Jail Suicide Data ........................................ 11

Personal Characteristics of the Victims ................................................................. 11

Characteristics of the Suicides ............................................................................ 19

Characteristics of the Jail Facilities....................................................................... 32


Chapter 4. Special Considerations ..................................................................... 43

The Changing Face of Jail Suicide ...................................................................... 43

Jail Suicide Rates .............................................................................................. 43


Chapter 5. Conclusion ...................................................................................... 47

Comprehensive Suicide-Prevention Programming................................................... 47

Future Training Efforts ........................................................................................ 53

Data Limitations and Further Research Needed ..................................................... 54

The Continuing Challenge of Prevention............................................................... 54


References....................................................................................................... 55

Appendix A. National Study of Jail Suicides Survey............................................ 59

Appendix B. National Study of Jail Suicides Questionnaire ................................. 61


Contents

iii

List of Tables

Table 1. Sources for Identifying Inmate Suicides in U.S. Jails: 2005–06 ...................8

Table 2. Total Number of Suicides Identified in U.S. Jails: 2005–06 ........................9

Table 3. Race of Suicide Victims in U.S. Jails: 2005–06.......................................12

Table 4. Gender of Suicide Victims in U.S. Jails: 2005–06...................................12

Table 5. Age of Suicide Victims in U.S. Jails: 2005–06........................................13

Table 6. Marital Status of Suicide Victims in U.S. Jails: 2005–06 ..........................14

Table 7. Most Serious Charge of Suicide Victims in U.S. Jails: 2005–06................15

Table 8. Most Serious Prior Charge of Suicide Victims in U.S. Jails: 2005–06 ........16

Table 9. History of Substance Abuse Among Suicide Victims in U.S. Jails: 

2005–06 ...............................................................................................16

Table 10. History of Medical Problems Among Suicide Victims in U.S. Jails: 

2005–06 ...............................................................................................17

Table 11. History of Mental Illness Among Suicide Victims in U.S. Jails: 

2005–06...........................................................................................18

Table 12. History of Psychotropic Medication Use Among Suicide Victims in 

U.S. Jails: 2005–06 ...........................................................................18

Table 13. History of Suicidal Behavior Among Suicide Victims in U.S. Jails: 

2005–06...........................................................................................19

Table 14. Month in Which Suicide Occurred in U.S. Jails: 2005–06.......................20

Table 15. Time of Day When Suicide Occurred in U.S. Jails: 2005–06 ...................21

Table 16. Length of Confinement Prior to Suicide in U.S. Jails: 2005–06 .................22

Table 17. Intoxication of Suicide Victims in U.S. Jails: 2005–06 .............................23

Table 18. Method of Suicide in U.S. Jails: 2005–06 .............................................24

Table 19. Instrument Used in Suicide in U.S. Jails: 2005–06 ..................................24

Table 20. Anchoring Device Used in Hanging in U.S. Jails: 2005–06 .....................25

Table 21. Time Span Between Last Observation and Finding Victim in 

U.S. Jails: 2005–06............................................................................26

Table 22. Administration of Cardiopulmonary Resuscitation (CPR) to Suicide 

Victims in U.S. Jails: 2005–06 .............................................................26

Table 23. Isolation or Segregation at Time of Death for Suicide Victims in 

U.S. Jails: 2005–06............................................................................27


List of
Content
Tabless

v

Table 24. Suicide Precaution Status Among Suicide Victims in U.S.
Jails: 2005–06...................................................................................28

Table 25. No-Harm Contracts Used in U.S. Jails: 2005–06....................................29

Table 26. Qualified Mental Health Professional (QMHP) Assessment of 

Suicide Victims in U.S. Jails: 2005–06 ..................................................29

Table 27. Suicide Victims’ Last Contact With a Qualified Mental Health 

Professional (QMHP) in U.S. Jails: 2005–06 ..........................................30

Table 28. Suicides Occurring Close to Date of Court Hearing in 

U.S. Jails: 2005–06............................................................................31

Table 29. Suicides Occurring Close to a Scheduled Court Hearing in

U.S. Jails: 2005–06............................................................................31

Table 30. Suicides Occurring Close to a Telephone Call or Visit in 

U.S. Jails: 2005–06 ...........................................................................32

Table 31. Suicides Occurring Close to a Scheduled Telephone Call or Visit in 

U.S. Jails: 2005–06............................................................................32

Table 32. Intake Screening for Suicide Risk in U.S. Jails: 2005–06 .........................33

Table 33. Verification of Suicide Risk During Prior Confinement in U.S. Jails: 

2005–06...........................................................................................34

Table 34. Arresting and/or Transporting Officer Opinion About Suicide Risk in 

U.S. Jails: 2005–06 ...........................................................................34

Table 35. Suicide-Prevention Training in U.S. Jails: 2005–06 .................................35

Table 36. Frequency of Suicide-Prevention Training in U.S. Jails: 2005–06 ..............36

Table 37. Certification in Cardiopulmonary Resuscitation (CPR) in U.S. Jails

That Sustained a Suicide: 2005–06......................................................36

Table 38. Suicide Watch Protocol in U.S. Jails: 2005–06 ......................................37

Table 39. Authorization To Discharge Inmates From Suicide Watch in 

U.S. Jails: 2005–06............................................................................38

Table 40. Safe Housing for Suicidal Inmates in U.S. Jails: 2005–06........................39

Table 41. Mortality Review Process in U.S. Jails: 2005–06 ....................................40

Table 42. Written Suicide-Prevention Policy in U.S. Jails: 2005–06 .........................41

Table 43. Changing Face of Suicide in U.S. Jails: 1985–86 to 2005–06 ................44


vi

National Study of Jail Suicide: 20 Years Later

Foreword

This report represents the third collaboration between the National Institute of Corrections and the
National Center on Institutions and Alternatives (NCIA) regarding national studies of jail suicide.
During the 1980s, two NCIA studies found high rates of suicide in county jails throughout the
country. Although suicide continues to be a leading cause of death in jails, the rate of suicide
continues to decrease, as demonstrated in this report, National Study of Jail Suicide: 20 Years
Later. Yet this report does more than simply present a calculation of suicide rates. It presents the
most comprehensive updated information on the extent and distribution of inmate suicides through­
out the country, including data on the changing face of suicide victims. Most important, the study
challenges both jail and health-care officials and their respective staffs to remain diligent in iden­
tifying and managing suicidal inmates. The National Institute of Corrections hopes that this report
will encourage continued research, training, and development and revision of comprehensive pre­
vention programs that are critical to the continued reduction of jail suicide throughout the country.

Morris L. Thigpen
Director
National Institute of Corrections

Foreword

vii

Acknowledgments

I would like to acknowledge several individuals for their assistance in completing this national
study of jail suicides. Catherine A. Gallagher, Ph.D., Associate Professor at George Mason
University’s Justice, Law and Crime Policy Program, was instrumental in the data analysis portion
of the project. As she has done on many prior occasions, Alice Boring of the National Center on
Institutions and Alternatives (NCIA) brought the report together to its final form.
The National Institute of Corrections (NIC) continues to be an advocate for suicide prevention in
correctional facilities. NIC provided the funding to NCIA to carry out this study and other national
studies on jail and prison suicide. NIC also previously funded NCIA’s Jail Suicide/Mental Health
Update, a quarterly newsletter distributed throughout the country at no charge to correctional and
health-care administrators, their staff, and other interested persons for more than 20 years.
Special thanks are extended to Virginia Hutchinson, Chief of the NIC Jails Division, and Fran
Zandi, Correctional Program Specialist in the NIC Jails Division and the program manager who
oversaw this project. This project would not have come to fruition without the support of Ms.
Hutchinson and Ms. Zandi, who were committed to finding the precious federal dollars necessary
to fund the study. I applaud their commitment and appreciate their patience with me in completing
this project.

Lindsay M. Hayes
Project Director
National Center on Institutions and Alternatives

Acknowledgments

ix

Executive Summary

Suicide continues to be a leading cause of death in jails across the country; the rate of suicide
in county jails is estimated to be several times greater than that in the general population. In
September 2006, the National Center on Institutions and Alternatives (NCIA) entered into a coop­
erative agreement with the National Institute of Corrections (NIC) to conduct a national study on
jail suicide that would determine the extent and distribution of inmate suicides in local jails (i.e.,
city, county, and police department facilities) and also gather descriptive data on the demographic
characteristics of each victim, characteristics of the incident, and characteristics of the jail facility
that sustained the suicide. The study, a followup to a similar national survey that NCIA conducted
in 1986, resulted in a report of the findings to be used as a resource tool for both jail person­
nel in expanding their knowledge base and correctional (as well as mental health and medical)
administrators in creating and/or revising policies and training curricula on suicide prevention.
The study identified 696 jail suicides in 2005 and 2006, with 612 deaths occurring in detention facilities
and 84 in holding facilities. Demographic data were subsequently analyzed on 464 of these suicides.
Following are some findings regarding characteristics of the suicide victims:
•	 Sixty-seven percent were white.
•	 Ninety-three percent were male.
•	 The average age was 35.
•	 Forty-two percent were single.
•	 Forty-three percent were held on a personal and/or violent charge.
•	 Forty-seven percent had a history of substance abuse.
•	 Twenty-eight percent had a history of medical problems.
•	 Thirty-eight percent had a history of mental illness.
•	 Twenty percent had a history of taking psychotropic medication.
•	 Thirty-four percent had a history of suicidal behavior.
Following are some findings regarding characteristics of the suicides:
•	 Deaths were evenly distributed throughout the year; certain seasons and/or holidays did not
account for more suicides.
•	 Thirty-two percent occurred between 3:01 p.m. and 9 p.m.
•	 Twenty-three percent occurred within the first 24 hours, 27 percent between 2 and 14 days,
and 20 percent between 1 and 4 months.

Executive Summary

xi

•	 Twenty percent of the victims were intoxicated at the time of death.
•	 Ninety-three percent of the victims used hanging as the method.
•	 Sixty-six percent of the victims used bedding as the instrument.
•	 Thirty percent of the victims used a bed or bunk as the anchoring device.
•	 Thirty-one percent of the victims were found dead more than 1 hour after the last observation.
•	 Cardiopulmonary resuscitation (CPR) was administered in 63 percent of incidents.
•	 Thirty-eight percent of the victims were held in isolation.
•	 Eight percent of the victims were on suicide watch at the time of death.
•	 No-harm contracts were used in 13 percent of cases.
•	 Thirty-seven percent of the victims were assessed by qualified mental health professionals; 47 of
the victims who committed suicide and were assessed saw a clinician within 3 days of death.
•	 Thirty-five percent occurred close to the date of a court hearing, with 80 percent occurring in
less than 2 days.
•	 Twenty-two percent occurred close to the date of a telephone call or visit, with 67 percent occur­
ring in less than 1 day.
Following are some findings regarding characteristics of the jail facilities:
•	 Eighty-four percent were administered by county, 13 percent by municipal, 2 percent by pri­
vate, and less than 2 percent by state or regional agencies.
•	 Seventy-seven percent provided intake screening to identify suicide risk, but only 27 percent
verified the victim’s suicide risk during prior confinement and only 31 percent verified whether
the arresting or transporting officer believed the victim was a suicide risk.
•	 Sixty-two percent provided suicide prevention training, but 63 percent either did not provide
training or did not provide it on an annual basis.
•	 Sixty-nine percent of training provided was for 2 hours or less, and only 6 percent was for a
duration of 8 hours.
•	 Eighty percent provided CPR certification.
•	 Ninety-three percent provided a protocol for suicide watch, but less than 2 percent had the
option for constant observation; most (87 percent) used 15-minute observation periods.
•	 Fifty-one percent allowed only mental health personnel to downgrade and discharge inmates
from suicide watch.
•	 Thirty-two percent maintained safe housing for suicidal inmates.
•	 Thirty-five percent maintained a mortality review process.
•	 Eighty-five percent maintained a written suicide prevention policy, but suicide prevention pro­
gramming was not comprehensive.

xii

National Study of Jail Suicide: 20 Years Later

Twenty years after the survey that was conducted in 1986, this national study of jail suicides found
substantial changes in the demographic characteristics of inmates who committed suicide. Some of
these changes were stark. For example, suicide victims once characterized as being confined on
“minor other” offenses were found in the 2005–06 data to be held on “personal and/or violent”
charges. Intoxication was previously viewed as a leading precursor to inmate suicide, yet recent data
indicate that it is now found in only a minority of cases. Whereas more than half of all jail suicide vic­
tims were dead within the first 24 hours of confinement according to 1986 data, current data suggest
that less than a quarter of all victims commit suicide during this time period, with an equal number of
deaths occurring between 2 and 14 days of confinement. In addition, inmates who committed suicide
appeared to be far less likely to be housed in isolation than previously reported and, for unknown
reasons, were less likely to be found within 15 minutes of the last observation by staff. Finally, more jail
facilities that experienced inmate suicides had both written suicide prevention policies and an intake
screening process to identify suicide risk than in years past, although the comprehensiveness of pro­
gramming remains questionable.
In 2006, the suicide rate in detention facilities was 36 deaths per 100,000 inmates, which is approxi­

In 2006, the suicide rate in

mately 3 times greater than that in the general population (Mumola and Noonan 2008). This rate,

detention facilities was 36 deaths

however, represents a dramatic decrease in the rate of suicide in detention facilities during the past 20

per 100,000 inmates.This rate

years. The nearly threefold decrease from a previously reported 107 suicides per 100,000 inmates

represents a dramatic decrease

in 1986 is extraordinary. Absent indepth scientific inquiry, there may be several explanations for the

in the rate of suicide in detention

reduced suicide rate. During the past several years, national studies of jail suicide have given a face to

facilities during the past 20 years.

this longstanding and often ignored public health issue in the nation’s jails. Study findings have been
widely distributed throughout the country and were eventually incorporated into suicide prevention train­
ing curricula. The increased awareness of inmate suicide is also reflected in national correctional stan­
dards that now require comprehensive suicide prevention programming, better training of jail staff, and
more indepth inquiry of suicide risk factors during the intake process. Finally, litigation involving jail
suicide has persuaded (or forced) jurisdictions and facility administrators to take corrective actions in
reducing the opportunity for future deaths. Therefore, based on this dramatic decrease in the rate of sui­
cides, the antiquated mindset that “inmate suicides cannot be prevented” should forever be put to rest.
This report offers recommendations in the areas of comprehensive suicide prevention programming,
staff training, and future research efforts.
In conclusion, findings from this study create a formidable challenge for both correctional and healthcare officials as well as their respective staff. Although our knowledge base continues to increase,
which has seemingly corresponded to a dramatic reduction in the rate of inmate suicide in deten­
tion facilities, much work lies ahead. The data indicate that inmate suicide is no longer centralized
to the first 24 hours of confinement and can occur at any time during an inmate’s confinement. As
such, because roughly the same number of deaths occurred within the first several hours of custody
as occurred during more than a few months of confinement, intake screening for the identification of
suicide risk upon entry into a facility should be viewed as time limited. Because inmates can be at risk
for suicide at any point during confinement, the biggest challenge for those who work in the correc­
tions system is to view the issue as requiring a continuum of comprehensive suicide prevention services
aimed at the collaborative identification, continued assessment, and safe management of inmates at risk
for self-harm.

Executive Summary

xiii

Chapter 1. Introduction

S

uicide continues to be a leading cause of death in jails across the country, where well
over 400 inmates take their lives each year (Hayes 2005). Mumola and Noonan (2008)
estimate the rate of suicide in county jails to be approximately three times greater than that

in the general population. Prior research indicates that most jail suicide victims were young white
males who were arrested for nonviolent offenses and were intoxicated upon arrest. Many were
placed in isolation and were dead within 24 hours of incarceration (Davis and Muscat 1993;
Hayes 1989), although more recent research (Frottier et al. 2002) found that jail inmates are at a
higher risk for suicide at both 24 to 48 hours and after 60 days of confinement. The overwhelm­
ing majority of victims were found hanging by either bedding or clothing. Most victims were not
adequately screened for potentially suicidal behavior upon entry into the jail (Hayes 1989). A dis­
proportionate number of suicide attempts involved inmates with mental illness (Goss et al. 2002).
Research specific to suicide in urban jail facilities provided some disparate findings. Most victims
of suicide in large urban facilities were arrested for violent offenses and were dead within 1 to 4
months of incarceration (DuRand et al. 1995; Marcus and Alcabes 1993). Because of the extend­
ed length of confinement prior to suicide, intoxication was not always the salient factor in urban
jails as it was in other types of jail facilities. Characteristics such as age, race, gender, method,
and instrument used were generally consistent in both urban and nonurban jails.
The precipitating factors of suicidal behavior in jail are well established (Bonner 1992, 2000;
Winkler 1992). Experts theorize that two primary causes for jail suicide exist: (1) jail environ­
ments are conducive to suicidal behavior and (2) the inmate is facing a crisis situation. From the
inmate’s perspective, certain features of the jail environment enhance suicidal behavior: fear of
the unknown, distrust of an authoritarian environment, perceived lack of control over the future,
isolation from family and significant others, shame of incarceration, and perceived dehumanizing
aspects of incarceration. In addition, certain factors are prevalent among inmates facing a crisis
situation that could predispose them to suicide: recent excessive drinking and/or drug use, recent
loss of stabilizing resources, severe guilt or shame over the alleged offense, current mental illness,
prior history of suicidal behavior, and approaching court date. In addition, some inmates simply
are (or become) ill equipped to handle the common stresses of confinement. During initial confine­
ment in a jail, this stress can be limited to fear of the unknown and isolation from family, but over
time (including stays in prison) it may become exacerbated and include loss of outside relation­
ships, conflicts within the institution, victimization, further legal frustration, physical and emotional
breakdown, and problems coping in the institutional environment (Bonner 1992). As the inmate
reaches an emotional breaking point, the result can be suicidal ideation (i.e., a wish to die without
a specific threat or plan), attempt, or completion.

Chapter 1. Introduction

1

Although suicide is well recognized as a critical problem in jails, the issue of prison suicide has
not received comparable attention, primarily because the number of jail suicides far exceeds the
number of prison suicides. Suicide ranks third (behind natural causes and AIDS) as the leading
cause of death in prisons (Mumola 2005). Even though the rate of suicide in prisons is consider­
ably lower than in jails, it still remains greater than the rate in the general population (Hayes
1995). Most research on prison suicide has found that the vast majority of victims are convicted
of personal crimes, housed in single cells (often some type of administrative confinement), and
have histories of prior suicide attempts and/or mental illness (Daniel and Fleming 2006; He et al.
2001; Patterson and Hughes 2008; Salive, Smith, and Brewer 1989; White and Schimmel 1995).
Although normally serving long sentences, most victims commit suicide in the early stages of their
prison confinement (New York State Department of Correctional Services 2002) as well as during
Suicide ranks third (behind
natural causes and AIDS) as
the leading cause of death
in prisons.

earlier stages of disciplinary confinement (Way et al. 2007). Precipitating factors in prison suicide
may include new legal problems, marital or relationship difficulties, and inmate-related conflicts
(Kovasznay et al. 2004).
Finally, an inmate’s suicide is emotionally devastating to the victim’s family and can be financially
devastating to the correctional facility (and its personnel) sustaining the death. Many inmate sui­
cides result in litigation against a state or local jurisdiction alleging that the cause of death was
negligence and/or deliberate indifference on the part of facility personnel. Although the plaintiff’s
burden to demonstrate liability in these cases remains high (Cohen 2008), several recent federal
court jury awards have well exceeded $1 million (Sanville v. Scaburdine 2002; Woodward v.
Myres 2003).

Prior Jail Suicide Research
In February 1988, the National Institute of Corrections released the National Center on Institutions
and Alternatives’ (NCIA’s) National Study of Jail Suicides: Seven Years Later (Hayes 1989),
which replicated an earlier national survey (And Darkness Closes In . . . A National Study of Jail
Suicides) that NCIA conducted in 1981 (Hayes 1983). The 1988 report was a compilation of
data gathered on jail suicides that occurred in 1986. About 30 percent of the 1986 suicides took
place in holding facilities (which normally detain persons for less than 48 hours) and about 70 per­
cent took place in detention facilities (which normally detain persons or house committed and/or
sentenced offenders for more than 48 hours but less than 2 years). Other findings are as follows:
•	 Seventy-two percent of victims were white.
•	 Ninety-four percent of victims were male.
•	 The average (mean) age of the victim was 30.
•	 Fifty-two percent of victims were single.
•	 Seventy-five percent of victims were detained on nonviolent charges, with 27 percent detained
on alcohol and/or drug-related charges.
•	 Eighty-nine percent of victims were confined as detainees.

2

National Study of Jail Suicide: 20 Years Later

•	 Seventy-eight percent of victims had prior charges, yet only 10 percent were previously held on
personal and/or violent offenses.
•	 Sixty percent of victims were intoxicated at the time of incarceration.
•	 Thirty percent of suicides occurred during a 6-hour period between midnight and 6 a.m.
•	 Ninety-four percent of suicides were by hanging.
•	 Forty-eight percent of victims used their bedding as the instrument.
•	 Two out of three victims were in isolation.
•	 Fifty-one percent of suicides occurred within the first 24 hours of incarceration; 29 percent
occurred within the first 3 hours.
•	 Eighty-nine percent of victims were not screened for potentially suicidal behavior at booking.
•	 Fifty-two percent of all victims charged with alcohol and/or drug-related offenses died within
the first 3 hours of confinement.
•	 Seventy-eight percent of victims who were intoxicated died within the first 24 hours of
incarceration; 48 percent died within the first 3 hours.
•	 The suicide rate in detention facilities was projected to be approximately nine times greater
than that in the general population.
In addition, data from holding facilities include the following:
•	 Forty-six percent of victims were held on alcohol and/or drug-related charges.
•	 Eighty-two percent of victims were intoxicated at the time of their incarceration.
•	 Sixty-four percent of victims died within the first 3 hours.
•	 Ninety-seven percent of victims were not screened for potentially suicidal behavior at booking.
Jail facilities that experienced a suicide in 1986 provided suicide prevention programs in only
58 percent of detention facilities and 32 percent of holding facilities. The study did not analyze
the quality of these programs. Despite minor variations, findings from the 1988 study were consis­
tent with NCIA’s 1981 national study of jail suicides (which used 1979 data). Allowing for slight
differences in characteristics of jail suicides, most of the key indicators (offense, intoxication, meth­
od and/or instrument, isolation, and length of incarceration) showed the same value over time.

A Word About Suicide Victim Profiles
Efforts to prevent suicide in jails are sometimes geared toward quick-fix solutions. These types of
approaches (e.g., use of closed-circuit television monitors, use of safety garments, and removal of
blankets) are usually attempts to treat only the symptom. Although these tools can be an important
part of jail suicide prevention, experts agree that they should never be used in lieu of staff training,
intervention, and supervision.

Chapter 1. Introduction

3

Suicide victim profiles have also fallen victim to quick-fix, superficial prevention techniques. At
times, these profiles are simply a mirror of a jail’s inmate population. Other times they seem to be
contradictory. When used without an awareness of potentially suicidal behavior, they are mislead­
ing. NCIA constructed and released its first victim profile from 1979 jail suicide data; at that time
it was equally praised and criticized. Although the profile appeared in many training manuals
throughout the country, it was maligned because critics claimed it allowed jail personnel to believe
that profiles can predict and thus prevent suicides. Further, critics charged that many of the charac­
teristics appearing in the suicide profile fit those of a typical jail inmate and, therefore, such a pro­
file was useless as a predictive tool. The primary objective of NCIA’s report—to help jail personnel
become sensitive to the characteristics or variables that appear most often in jail suicide victims—
became lost in the controversy. Quick-fix advocates embraced NCIA’s profile, while foes argued
that “not all jail suicides occur on Saturday nights in September.” Both camps missed the point.
Demographic victim profiles cannot predict suicide risk; jail officials have been warned that these
profiles should only be used to help correctional personnel understand the general risk of sui­
cide for those in custody (Hayes 1989; Winter 2003). As stated by Farmer and colleagues: “In
predicting who will be at risk over time, factors such as mental disorders, prior psychiatric hospi­
talizations, prior suicidal and self-destructive acts, substance abuse, and ongoing stressors may
eventually prove to be more useful danger signals than demographic variables such as age, race,
and gender” (Farmer, Felthous, and Holzer 1996:246). That is, a demographic profile of suicide
victims should not be viewed as a “death certificate” for all inmates in the nation’s jails, nor should
jail personnel ignore those inmates who exhibit suicidal tendencies but do not fit within certain
demographic variables. The fundamental goal of a victim profile is to help correctional, medical,
and mental health personnel become sensitive to the characteristics that appear most often in jail
suicide victims, while at the same time acting as a supplement to the warning signs of potential
suicidal behavior. In essence, ignoring obvious signs of potentially suicidal behavior because the
individual does not fit the profile is not only foolish, but also negligent.

Death in Custody Reporting Act of 2000
Before 2000, state and local jurisdictions did not have uniform requirements for reporting the cir­
cumstances surrounding the deaths of inmates in their custody, and some had no system for requir­
ing such reports. Therefore, the number of individuals who were dying in custody and the causes
of death could not be determined. The two national studies of jail suicides that NCIA released
in 1981 and 1988 provided the only data regarding the extent and scope of inmate suicides
throughout the country.
Signed into law on October 13, 2000, the Death in Custody Reporting Act of 2000 (Public Law
106–297) requires each state that receives prison construction funding under the federal truth-in­
sentencing incentive grant program to “report, on a quarterly basis, information regarding the
death of any person who is in the process of arrest, is en route to be incarcerated, or is incarcerat­
ed at a municipal or county jail, state prison, or other local or state correctional facility (including
any juvenile facility) that, at a minimum, includes (a) the name, gender, race, ethnicity, and age of

4

National Study of Jail Suicide: 20 Years Later

the deceased; (b) the date, time, and location of death, and (c) a brief description of the circum­
stances surrounding the death.” The Bureau of Justice Statistics (BJS) is responsible for collecting
and analyzing the data, and implemented the Act over a 4-year period. Data collection on deaths
in local jail facilities began in 2000, followed by collection from state prisons in 2001. In 2002,
BJS began collecting records of deaths from all state juvenile correctional systems, and in 2003, it
began collecting data on arrest-related deaths involving approximately 17,784 state and local law
enforcement agencies throughout the country. BJS requests data quarterly and reports it annually.
According to the most recent BJS data, 277 inmate suicides occurred in more than 3,000 jail
facilities in 2006 (Mumola and Noonan 2008).1 The suicide rate in these jails was calculated
to be 36 deaths per 100,000 inmates. During the period 2000–06, the BJS data found that 92
percent of jail suicide victims were male, 70 percent were white, and most were 25 to 44 years
old. Earlier BJS data (Mumola 2005) found that white jail inmates were six times more likely than
African-American inmates, and more than three times more likely than Hispanic inmates, to com­
mit suicide. In addition, male inmates had higher rates of suicide than female inmates, and violent
offenders had a much higher suicide rate than nonviolent offenders. Almost half of the jail suicides
occurred during an inmate’s first week in custody (Mumola 2005).

1

For purposes of reporting on the number of deaths in custody, jail facilities excluded law enforcement and police department
lockups, privately operated jails, and facilities operated by multiple jurisdictions (e.g., regional jails). In 2003, BJS began survey­
ing law enforcement and police department lockups to obtain these data, which are not available to date.

Chapter 1. Introduction

5

Chapter 2.
National Study of Jail Suicides: 20 Years Later

H

istorically, jail suicides have created publicity, increased public awareness, and ultimately
led to litigation against jail facilities, city governments, county commissioners, and others.
The past 20 years have produced national studies on inmate suicide, training curricula on

suicide prevention in correctional facilities, and revised suicide prevention provisions in national
correctional standards that call for increased emphasis on suicide risk inquiry at intake. There is
little argument that jail administrators are far more aware of the suicide risk in their facilities today
than in years past. Most important are indications that the suicide rate in U.S. jails has fallen sub­
stantially. In 1988, the National Center on Institutions and Alternatives’ (NCIA’s) national study of
jail suicides calculated that there were 107 county jail suicides per 100,000 inmates in 1986, a
rate about 9 times greater than that in the general population.2 As stated in chapter 1, the Bureau
of Justice Statistics (BJS) recently calculated that in 2006 the suicide rate in these jails was 36
deaths per 100,000 inmates, which is about 3 times greater than that in the general population.
Because the last comprehensive national study on jail suicides was conducted more than 20 years
ago and BJS data, although useful, are limited to basic demographic information (e.g., age, race,
gender, most serious offense, length of confinement), the current study was born out of the belief
that a new, comprehensive study regarding the total scope and extent of inmate suicides in jails
and lockups throughout the country was long overdue.
In September 2006, NCIA entered into a cooperative agreement with the National Institute of
Corrections (NIC) to conduct a national study on jail suicides that would determine the extent and
distribution of inmate suicides in local jails (i.e., city, county, and police department facilities) and
to collect data on the demographic characteristics of each victim, each incident, and the jail facil­
ity that sustained the suicide. A report of the findings would become a resource tool to help jail
personnel expand their knowledge base and help correctional (as well as mental health and medi­
cal) administrators create and/or revise policies and training curricula on suicide prevention.

Methodology: Phase 1
This survey, the third national study that NCIA conducted for NIC (see Hayes 1983 and 1989),
was divided into two phases. During phase 1, surveys were mailed to 15,978 facilities across
the United States, including 3,173 county jails and 12,805 law enforcement agencies that admin­
istered short-term lockups. Each respondent was asked to complete a one-page survey if his/her
facility sustained one or more suicides in 2005 and/or 2006 (see appendix A). A jail was defined
2

According to Heron and colleagues (2009), the suicide rate in the general population is approximately 11 deaths per
100,000 citizens.

Chapter 2. National Study of Jail Suicides: 20 Years Later

7


as any facility operated by a local jurisdiction (e.g., county, municipality), private entity, or multijurisdictional authority whose purpose was to confine individuals primarily apprehended by law
enforcement personnel. Per this definition, jails included temporary holding and pretrial detention
facilities, lockup facilities that normally detained individuals for less than 72 hours, and facilities
that normally detained individuals or housed committed and/or sentenced offenders for more than
72 hours. The definition also included facilities that housed inmates from other jurisdictions (e.g., a
state or federal prison system), including privately operated jails and regional jails.
Phase 1 surveys were mailed to all jail facilities in July and August 2007. Return business reply
envelopes were included in the mailing to ensure a higher rate of return. Further, to help verify
data, survey forms were also sent (from September through December 2007) to state medical
examiner offices, state and federal jail inspection and/or regulatory agencies, state police/bureau
of investigation offices, and private health-care providers that had contracts with county and
municipal jurisdictions. Finally, an Internet search engine was used to search newspaper articles on
inmate suicides that were not identified through other sources.
Phase 1 data identified a total of 696 jail suicides in 2005 and 2006 (366 in 2005 and 330 in
2006). The suicides occurred in 47 states and the District of Columbia.3 Table 1 shows that 383
(55 percent) of the deaths were identified through jail facilities’ self-reports. Data from state inspec­
tion, investigation, and regulatory agencies showed an additional 177 (25.4 percent) suicides
that were not identified through self-reports. Of the remaining deaths, 92 (13.2 percent) were
identified through the Internet and newspaper articles, 28 (4.1 percent) through state medical
examiner offices, 12 (1.7 percent) through private health-care providers, and 4 (0.6 percent) from
other sources.4

Table 1. Sources for Identifying Inmate Suicides in U.S. Jails: 2005–06
SOURCE

NUMBER

PERCENT

Self-report

383

55.0

Inspection, investigation, and
regulatory agencies

177

25.4

Internet and newspaper articles

92

13.2

Medical examiners

28

4.1

Private health-care providers

12

1.7

4

0.6

696

100.0

Other
Total

Source: National Institute of Corrections and National Center on Institutions and Alternatives, National Study
of Jail Suicides, 2006.

3

No suicides were reported in Alaska, Hawaii, and Vermont.

4

Other sources were from the project director’s expert witness consultation and/or technical assistance to facilities that sustained
these deaths.

8

National Study of Jail Suicide: 20 Years Later

It is important to note that “self-report” is the primary category for identifying jail suicide. For
example, if a jail suicide was identified by multiple sources, including a self-report from the facility
in which the suicide occurred, the source would be attributed to a self-report. Table 1 is intended
to reflect a survey respondent’s willingness to self-report an inmate suicide within his/her facility
rather than the data collection efforts of state inspection and/or regulatory agencies, state medical
examiners, or other organizations.
A total of 696 jail suicides were identified during phase 1—in 2005, 324 deaths occurred in de­
tention facilities and 42 occurred in holding facilities and in 2006, 288 deaths occurred in deten­
tion facilities and 42 occurred in holding facilities (see table 2). The vast majority (89 percent) of
suicides occurred in detention facilities (612 of 696 deaths).

Table 2. Total Number of Suicides Identified in U.S. Jails: 2005–06
FACILITY TYPE
HOLDING
(0–72 hours)

YEAR

DETENTION
(>72 hours)

COMBINED

NUMBER

PERCENT

NUMBER

PERCENT

NUMBER

PERCENT

2005

42

50.0

324

52.9

366

52.6

2006

42

50.0

288

47.1

330

47.4

Total

84

100.0

612

100.0

696

100.0

Source: National Institute of Corrections and National Center on Institutions and Alternatives, National Study
of Jail Suicides, 2006.

Methodology: Phase 2
In phase 1, facilities that experienced one or more suicides in 2005 and/or 2006 were identified. 

In phase 2, the survey process was initiated, including dissemination of an eight-page survey 

instrument to facility administrators (see appendix B). The survey instrument was designed to collect 

the following data:

•	 Demographic characteristics of each victim, including but not limited to age, gender, race, liv­
ing status, current offense(s), prior offense(s), legal status (detained or sentenced), length of con­
finement, alcohol and/or drug intoxication at confinement, history of isolation or segregation,
room confinement, substance abuse history, medical and/or mental health history, psychotropic
medication history, and history of suicidal behavior.
•	 Characteristics of each incident, including but not limited to date, time, and location of suicide;
intoxication at time of incident; housing assignment (e.g., single or multiple occupancy, whether
the victim was in isolation or segregation and/or on suicide watch); method and instrument
used; time span between when the incident occurred and when the victim was found; whether
cardiopulmonary resuscitation (CPR) and/or an automated external defibrillator were used in
emergency response; whether a “no-harm” contract was used prior to the incident; whether the

Chapter 2. National Study of Jail Suicides: 20 Years Later

9

victim attended a court hearing, received a visit or telephone call, and/or was assessed by a
qualified mental health professional close to the date of the incident; and any possible precipi­
tating factors to the suicide.
•	 Facility characteristics, including but not limited to facility type; facility ownership (e.g., state,
county, private); capacity and/or population when the suicide occurred; and the suicideprevention measures in place at the time of the incident (e.g., written policy, intake screening,
staff training in suicide prevention and CPR, observation levels, safe housing, and mortality
review).
In January 2008, phase 2 survey instruments were initially mailed to facility administrators of
the 696 facilities that sustained suicides; 422 surveys were completed and returned. Between
March and August 2008, facility administrators who did not respond to the initial survey received
a followup letter and a phone call; as a result, an additional 42 surveys were completed and
returned. Survey respondents were given the following assurances verbally and in writing: “Data
provided will be coded and held in the strictest confidence. Results of this study will be presented
in summary fashion, therefore, victim and facility names will not appear in any project report.”
Nevertheless, some facility administrators did not cooperate with requests to complete the survey.
In September 2008, data collection efforts were concluded with a final response rate of 67 per­
cent (464 responses out of 696 surveys).5

5

The response rate for this study was lower than the rates from the two earlier studies of jail suicide (82 percent for the 1981
study and 85 percent for the 1988 study). Facility administrators gave several reasons for not fully participating in the study,
including ongoing litigation and advice from legal counsel, sensitivity of the subject matter, issues of confidentiality, and time
and/or manpower constraints. Some respondents incorrectly stated that completing the survey would violate the Health Insurance
Portability and Accountability Act Privacy Rule. In addition, some facility administrators may have decided not to participate in the
process because of the time it would have taken to complete the comprehensive eight-page survey instrument.

10

National Study of Jail Suicide: 20 Years Later

Chapter 3.
Demographic Findings of Jail Suicide Data

A

s stated in chapter 2, project staff analyzed data on 464 of the 696 jail suicides identi­
fied between 2005 and 2006. Demographic findings in this section will be presented in
relationship to the type of jail facility. For purposes of this analysis, two facility types were

considered: (1) holding facilities (which normally detain individuals for less than 72 hours) and
(2) detention facilities (which normally detain individuals or house committed and/or sentenced
offenders for more than 72 hours but less than 2 years). Twelve percent (58) of the jail suicides
took place in holding facilities and 88 percent (406) took place in detention facilities. Although
the data presented in the following tables are categorized by facility type rather than by the juris­
dictional agency that controls the facility, it is important to note that 84 percent of the suicides
occurred in facilities operated by county governments, nearly 13 percent in facilities operated by
municipal governments, less than 2 percent in facilities operated by private organizations, and less
than 2 percent in facilities operated by multijurisdictional authorities.

African-American inmates,
who account for nearly the
same percentage of the
total jail population as
whites, constitute a much
lower percentage of jail

Personal Characteristics of the Victims

suicide victims.

Race
Table 3 shows that approximately two-thirds (67.2 percent) of suicide victims were white, 15.1 per­
cent were African American, 12.7 percent were Hispanic, and 2.8 percent were American Indian.
These percentages are consistent with both the National Center on Institutions and Alternatives’
(NCIA’s) 1988 study (Hayes 1989) and recent Bureau of Justice Statistics (BJS) data (Mumola and
Noonan 2008). More white victims committed suicide in detention facilities than holding facilities
and more Hispanic victims committed suicide in holding facilities than detention facilities.6 Of note
is that, although white inmates account for about 44 percent of the total jail population throughout
the country, they represent the majority (67 percent) of inmates who committed suicide, whereas
African-American inmates, who account for nearly the same percentage of the total jail population
as whites (39 percent), constitute a much lower percentage of jail suicide victims (15 percent).7
Other recent BJS data also found that white inmates had higher rates of suicide than AfricanAmerican inmates (Mumola 2005). The cause of this disproportionate relationship is outside the
purview of this survey.

6

For purposes of this study, differences greater than 10 percent will be considered significant.

7

For comparative data on jail inmates, see Minton and Sabol 2009.

Chapter 3. Demographic Findings of Jail Suicide Data

11


Table 3. Race of Suicide Victims in U.S. Jails: 2005–06
FACILITY TYPE
HOLDING
(0–72 hours)

RACE

DETENTION
(>72 hours)

COMBINED

NUMBER

PERCENT

NUMBER

PERCENT

NUMBER

PERCENT

White

32

55.2

280

68.9

312

67.2

African American

11

19.0

59

14.5

70

15.1

Hispanic

14

24.1

45

11.1

59

12.7

American Indian

1

1.7

12

3.0

13

2.8

Other

0

0.0

10

2.5

10

2.2

Total

58

100.0

406

100.0

464

100.0

Source: National Institute of Corrections and National Center on Institutions and Alternatives, National Study
of Jail Suicides, 2006.

Gender
An overwhelming majority (93.1 percent) of the victims were male. The data presented in table 4
are consistent with both NCIA’s 1988 study (Hayes 1989) and recent BJS data (Mumola and
Noonan 2008). No significant gender differences were found between suicides that occurred in
holding and detention facilities. These findings are not surprising because the vast majority of jail
inmates throughout the country are male (Minton and Sabol 2009).

Table 4. Gender of Suicide Victims in U.S. Jails: 2005–06
FACILITY TYPE
HOLDING
(0–72 hours)

GENDER

Male
Female
Total

DETENTION
(>72 hours)

COMBINED

NUMBER

PERCENT

NUMBER

PERCENT

NUMBER

PERCENT

54

93.1

378

93.1

432

93.1

4

6.9

28

6.9

32

6.9

58

100.0

406

100.0

464

100.0

Source: National Institute of Corrections and National Center on Institutions and Alternatives, National Study
of Jail Suicides, 2006.

12

National Study of Jail Suicide: 20 Years Later

Age
Table 5 shows that more than one-third of all suicide victims (approximately 36 percent) were ages
33 to 42. Only four victims (0.9 percent) were 17 or younger, and the average age was 35.
These percentages are slightly higher than those from both NCIA’s 1988 study (Hayes 1989) and
recent BJS data (Mumola and Noonan 2008). No significant age differences were found between
suicides that occurred in holding and detention facilities.

Table 5. Age of Suicide Victims in U.S. Jails: 2005–06
FACILITY TYPE
HOLDING
(0–72 hours)

AGE

NUMBER

DETENTION
(>72 hours)

PERCENT

NUMBER

COMBINED

PERCENT

NUMBER

PERCENT

≤17

1

1.7

3

0.7

4

0.9

18–22

5

8.6

55

13.5

60

12.9

23–27

7

12.1

58

14.3

65

14.0

28–32

8

13.8

48

11.8

56

12.1

33–37

12

20.7

72

17.8

84

18.0

38–42

13

22.5

70

17.3

83

17.9

43–47

6

10.3

57

14.0

63

13.6

48–53

5

8.6

21

5.2

26

5.6

≥53

1

1.7

22

5.4

23

5.0

Total

58

100.0

406

100.0

464

100.0

Source: National Institute of Corrections and National Center on Institutions and Alternatives, National Study
of Jail Suicides, 2006.

Marital Status
Forty-two percent of the victims were single, 21.4 percent were married or living in a common-law
relationship, and 8.8 percent were divorced (see table 6). The remaining 4.7 percent were either
separated or widowed. These percentages are consistent with the findings from NCIA’s 1988 study
(Hayes 1989). More single inmates committed suicide in detention facilities than holding facilities,
and slightly more married inmates committed suicide in holding facilities than detention facilities.
No information is available on the marital status of almost one-quarter of all suicide victims, a find­
ing that might relate to the inadequacy of intake screening at facilities that sustained the suicides.

Chapter 3. Demographic Findings of Jail Suicide Data

13

Table 6. Marital Status of Suicide Victims in U.S. Jails: 2005–06
FACILITY TYPE
HOLDING
(0–72 hours)

MARITAL STATUS

DETENTION
(>72 hours)

NUMBER

PERCENT

NUMBER

Single

19

32.8

176

Married

15

25.9

Common law

4

Separated

COMBINED

PERCENT

NUMBER

PERCENT

43.3

195

42.0

74

18.2

89

19.2

6.9

6

1.5

10

2.2

2

3.4

13

3.2

15

3.2

Divorced

4

6.9

37

9.1

41

8.8

Widowed

1

1.7

6

1.5

7

1.5

Unknown

13

22.4

94

23.2

107

23.1

Total

58

100.0

406

100.0

464

100.0

Source: National Institute of Corrections and National Center on Institutions and Alternatives, National Study
of Jail Suicides, 2006.

Most Serious Charge
For purposes of this study, the most serious charge was broken down into four offense categories:
personal and/or violent, serious property, alcohol and/or drug related, and minor other. Table 7
shows that 43.4 percent of the victims were charged with a personal and/or violent offense(s),
followed by minor other (22.5 percent), alcohol and/or drug related (19.0), and serious property
(15.1 percent). These data vary widely from the findings of NCIA’s 1988 study (Hayes 1989),
which showed that suicide victims were fairly evenly distributed across the four offense categories
and that personal and/or violent charges accounted for only 24.7 percent of victims. These current
data, however, are consistent with other recent BJS data that also found that inmates charged with
violent offenses had higher rates of suicide than those charged with nonviolent offenses (Mumola
2005). More inmates charged with alcohol and/or drug-related offenses committed suicide in hold­
ing facilities than detention facilities and more inmates charged with serious property offenses com­
mitted suicide in detention facilities than holding facilities.
In almost 50 percent of jail suicides, the victims had been charged with one or more of the follow­
ing offenses: sexual assault and/or murder of a child (32), possession of drugs (27), murder (24),
burglary (21), driving while intoxicated (21), rape/sexual assault (20), assault (19), aggravated
assault (17), domestic violence (17), and attempted murder (16). The single charge of sexual
assault and/or murder of a child was associated with approximately 7 percent of all jail suicides.

14

National Study of Jail Suicide: 20 Years Later

Table 7. Most Serious Charge of Suicide Victims in U.S. Jails: 2005–06
FACILITY TYPE
HOLDING
(0–72 hours)

MOST SERIOUS CHARGE

NUMBER
Personal and/or violent
Serious property
Alcohol and/or drug related
Minor other
Total

DETENTION
(>72 hours)

PERCENT

COMBINED

NUMBER

PERCENT

NUMBER

PERCENT

23

39.7

178

43.8

201

43.4

4

6.9

66

16.3

70

15.1

22

37.9

67

16.5

89

19.0

9

15.5

95

23.4

104

22.5

58

100.0

406

100.0

464

100.0

Notes: “Personal and/or violent” includes murder, negligent manslaughter, armed robbery, rape, sexual assault,
indecent assault, child abuse, domestic violence, assault, battery, aggravated assault, kidnapping, and other
offenses. “Serious property” includes burglary, grand larceny, auto theft, robbery (other), receiving stolen prop­
erty, arson, breaking and entering, entering without breaking, vandalism, carrying a concealed weapon and/or
firearm, and other offenses. “Alcohol and/or drug related” includes public intoxication, driving while intoxicated,
disorderly conduct, resisting arrest, possession and/or distribution of controlled dangerous substances, narcotics
(unspecified), and other offenses. “Minor other” includes shoplifting, petty larceny, prostitution, sex offenses (other),
trespassing, unauthorized use of motor vehicle, traffic offenses (other), violation of probation, contempt of court,
vagrancy, indecent exposure, status offenses, escape, forgery, embezzlement, and other offenses.
Source: National Institute of Corrections and National Center on Institutions and Alternatives, National Study
of Jail Suicides, 2006.

Additional Charges and Jail Status
Almost 42 percent of inmates who committed suicide had a second current charge filed against
them,8 and the overwhelming majority (90.1 percent) of suicide victims were in detention facilities
at the time of their death. These percentages are consistent with the findings from NCIA’s 1988
study (Hayes 1989). However, these data are quite different from those of inmates who do not
commit suicide. Current BJS data indicate that 62 percent of all inmates confined in U.S. jails in
2006 were on detention status (Minton and Sabol 2009). The fact that most inmates who commit­
ted suicide were on detention status at the time of their deaths may be related to the shorter length
of confinement prior to the suicide (see table 16, page 22).

Most Serious Prior Charge
More than one-third (37.7 percent) of the inmates who committed suicide did not have a history
of prior arrests (see table 8). The data also show that 19.6 percent of the victims were charged
with a minor other offense, followed by alcohol and/or drug related (19.4 percent), personal
and/or violent (16.0 percent), and serious property (7.3 percent). These percentages are some­
what consistent with the findings from NCIA’s 1988 study, although that study indicated fewer
(21.8 percent) victims with no history of prior arrests (Hayes 1989). No significant differences
were found between suicides that occurred in holding and detention facilities in regard to the most
serious prior charge.
8

Data were recorded on only the two most serious charges filed against inmates who committed suicide; more than two charges
were filed against only a small percentage of victims.

Chapter 3. Demographic Findings of Jail Suicide Data

15

Table 8. Most Serious Prior Charge of Suicide Victims in U.S. Jails: 2005–06
FACILITY TYPE
MOST SERIOUS
PRIOR CHARGE

HOLDING
(0–72 hours)
NUMBER

DETENTION
(>72 hours)

PERCENT

COMBINED

NUMBER

PERCENT

NUMBER

PERCENT

Personal and/or violent

8

13.8

66

16.2

74

16.0

Serious property

1

1.7

33

8.1

34

7.3

Alcohol and/or drug related

13

22.4

77

19.0

90

19.4

Minor other

12

20.7

79

19.5

91

19.6

None

24

41.4

151

37.2

175

37.7

Total

58

100.0

406

100.0

464

100.0

Source: National Institute of Corrections and National Center on Institutions and Alternatives, National Study
of Jail Suicides, 2006.

History of Substance Abuse
Nearly 47 percent of inmates who committed suicide were identified during the intake process as
having a history of substance abuse (see table 9). Most victims used alcohol, marijuana, synthetic
drugs (e.g., methamphetamine, PCP, OxyContin), or multiple illegal drugs. These data are consis­
tent with available BJS data on substance abuse history among inmates in U.S. jails (Karberg and
James 2005). No significant differences were found between suicides that occurred in holding
and detention facilities in regard to substance abuse. No information is available on the substance
abuse history of approximately 35 percent of all inmates who committed suicide, a finding that
might relate to the inadequacy of intake screening in facilities that sustained the suicides.

Table 9. History of Substance Abuse Among Suicide Victims in U.S. Jails: 2005–06
FACILITY TYPE
SUBSTANCE
ABUSE

HOLDING
(0–72 hours)
NUMBER

DETENTION
(>72 hours)

COMBINED

PERCENT

NUMBER

PERCENT

NUMBER

PERCENT

Yes

29

50.0

188

46.3

217

46.8

No

11

19.0

72

17.7

83

17.9

Unknown

18

31.0

146

36.0

164

35.3

Total

58

100.0

406

100.0

464

100.0

Source: National Institute of Corrections and National Center on Institutions and Alternatives, National Study
of Jail Suicides, 2006.

16

National Study of Jail Suicide: 20 Years Later

History of Medical Problems
Only 27.6 percent of inmates who committed suicide indicated a history of medical problems
(e.g., cardiac issues, seizures, diabetes, hypertension, asthma) during the intake process (see
table 10). This is somewhat lower than available BJS data on medical problems among inmates
in U.S. jails (Maruschak 2006). Significant differences were found between suicides that occurred
in holding and detention facilities in regard to medical problems; holding facilities reported fewer
medical problems. No information is available about medical concerns in approximately 30 per­
cent of all inmates who committed suicide, a finding that might relate to the inadequacy of intake
screening in facilities that sustained the suicides.

Table 10. History of Medical Problems Among Suicide Victims in U.S. Jails: 2005–06
FACILITY TYPE
MEDICAL
PROBLEMS

HOLDING
(0–72 hours)
NUMBER

DETENTION
(>72 hours)

PERCENT

COMBINED

NUMBER

PERCENT

NUMBER

PERCENT

Yes

5

8.6

123

30.3

128

27.6

No

32

55.2

166

40.9

198

42.7

Unknown

21

36.2

117

28.8

138

29.7

Total

58

100.0

406

100.0

464

100.0

Source: National Institute of Corrections and National Center on Institutions and Alternatives, National Study
of Jail Suicides, 2006.

History of Mental Illness
The research literature on suicide in the general community shows a strong relationship between
suicide and mental illness. Although the vast majority of individuals who suffer from mental illness
do not commit suicide, it is estimated that more than 90 percent of suicides are associated with
mental or addictive disorders and that approximately two-thirds of individuals who commit suicide
are depressed at the time of their deaths (Moscicki 2001).
Only 38.1 percent of inmates who committed suicide were identified as having a history of mental
illness during the intake process (see table 11). Most inmates with mental illness who later commit­
ted suicide suffered from depression or psychosis.9 The percentage of victims with mental illness
was also significantly lower than available BJS data on mental health problems among inmates in
U.S. jails. For example, recent BJS data show that 64 percent of jail inmates reported a history of
mental health problems and 61 percent reported symptoms of mental health disorders within the
past 12 months (James and Glaze 2006). Significant differences were found between suicides that
occurred in holding and detention facilities in regard to prior mental illness, with holding facilities
reporting far fewer such issues. No information is available about the mental health of approxi­
mately 30 percent of all inmates who committed suicide. This finding, along with the relatively low
9

Survey respondents did not list the victims’ mental illness according to the Diagnostic and Statistical Manual III or IV criteria.

Chapter 3. Demographic Findings of Jail Suicide Data

17

reporting rate of mental illness in jail suicide victims (particularly in holding facilities), might relate
to the inadequacy of intake screening in facilities that sustained the suicides.

History of Psychotropic Medication
Nearly 20 percent of inmates who committed suicide took psychotropic medication to treat their
mental illness, and most were reported to have taken an antidepressant (see table 12). This is
consistent with available BJS data on the use of psychotropic medication by inmates in U.S. jails
(James and Glaze 2006). The findings also indicated that approximately 16 percent of all inmates
who committed suicide were receiving psychotropic medication at the time of their death. Only
slight differences were found between suicides that occurred in holding and detention facilities in
regard to the use of psychotropic medication. No information is available about the use of psycho­
tropic medication in approximately 40 percent of all inmates who committed suicide, a finding that
might relate to the inadequacy of intake screening in facilities that sustained the suicides.

Table 11. History of Mental Illness Among Suicide Victims in U.S. Jails: 2005–06
FACILITY TYPE
MENTAL
ILLNESS

HOLDING
(0–72 hours)
NUMBER

DETENTION
(>72 hours)

PERCENT

COMBINED

NUMBER

PERCENT

NUMBER

PERCENT

Yes

14

24.1

163

40.1

177

38.1

No

23

39.7

123

30.3

146

31.5

Unknown

21

36.2

120

29.6

141

30.4

Total

58

100.0

406

100.0

464

100.0

Source: National Institute of Corrections and National Center on Institutions and Alternatives, National Study
of Jail Suicides, 2006.

Table 12. History of Psychotropic Medication Use Among Suicide Victims in U.S. Jails: 2005–06
FACILITY TYPE
PSYCHOTROPIC
MEDICATION

HOLDING
(0–72 hours)

DETENTION
(>72 hours)

COMBINED

NUMBER

PERCENT

NUMBER

PERCENT

NUMBER

PERCENT

Yes

7

12.0

85

20.9

92

19.8

No

19

32.8

169

41.7

188

40.5

Unknown

32

55.2

152

37.4

184

39.7

Total

58

100.0

406

100.0

464

100.0

Source: National Institute of Corrections and National Center on Institutions and Alternatives, National Study
of Jail Suicides, 2006.

18

National Study of Jail Suicide: 20 Years Later

History of Suicidal Behavior
The research literature on suicide in jails shows a strong relationship between suicide and a history
of suicidal behavior. A history of suicide attempts has consistently been shown to be one of the
strongest risk factors for completed suicides (Moscicki 2001). Although the vast majority of indi­
viduals who think about suicide and/or engage in suicidal behavior do not commit suicide, it is
estimated that 20 to 50 percent of individuals who commit suicide made a previous attempt to do
so (American Foundation for Suicide Prevention 2009).
Only 33.8 percent of inmates who committed suicide reported a history of suicidal behavior
during the intake process (see table 13). The percentage of victims who had a history of sui­
cidal behavior is significantly higher than available BJS data on prior suicidal behavior among
inmates in U.S. jails (James and Glaze 2006). Recent BJS data indicate that only 13 percent of
jail inmates reported one or more suicide attempts within the past 12 months (James and Glaze
2006). Significant differences were found between suicides that occurred in holding and detention
facilities in regard to prior suicidal behavior, with holding facilities reporting far less behavior. No
information is available on the prior suicidal behavior of approximately 24 percent of all inmates
who committed suicide; this finding, along with the relatively low identification of prior suicidal
behavior in jail suicide victims, might relate to the inadequacy of intake screening in facilities that
sustained the suicides.

Table 13. History of Suicidal Behavior Among Suicide Victims in U.S. Jails: 2005–06
FACILITY TYPE
SUICIDAL
BEHAVIOR

HOLDING
(0–72 hours)

DETENTION
(>72 hours)

COMBINED

NUMBER

PERCENT

NUMBER

PERCENT

NUMBER

PERCENT

Yes

11

19.0

146

36.0

157

33.8

No

29

50.0

168

41.4

197

42.5

Unknown

18

31.0

92

22.6

110

23.7

Total

58

100.0

406

100.0

464

100.0

Source: National Institute of Corrections and National Center on Institutions and Alternatives, National Study
of Jail Suicides, 2006.

Characteristics of the Suicides
Date
Fifty-two percent (240) of the suicides occurred in 2005 and 48 percent (224) occurred in 2006.
The suicides were fairly evenly distributed throughout the year, although more than 22 percent
occurred in July and August (see table 14). This is similar to the findings from NCIA’s 1988 study
(Hayes 1989). Contrary to common belief, particular seasons and/or holidays did not account
for a significantly higher number of suicides, a finding confirmed by other research on suicide in

Chapter 3. Demographic Findings of Jail Suicide Data

19

Table 14. Month in Which Suicide Occurred in U.S. Jails: 2005–06
FACILITY TYPE
HOLDING
(0–72 hours)

MONTH

DETENTION
(>72 hours)

COMBINED

NUMBER

PERCENT

NUMBER

January

6

10.3

32

7.9

38

8.2

February

3

5.2

21

5.2

24

5.2

10

17.4

32

7.9

42

9.1

April

2

3.4

39

8.9

41

8.8

May

5

8.6

36

8.9

41

8.8

June

2

3.4

33

8.1

35

7.6

July

6

10.3

51

12.8

57

12.3

August

4

6.9

43

10.8

47

10.2

September

3

5.2

28

6.9

31

6.7

October

4

6.9

29

7.2

33

7.1

November

6

10.3

31

7.7

37

7.8

December

7

12.1

31

7.7

38

8.2

58

100.0

406

100.0

464

100.0

March

Total

PERCENT

NUMBER

PERCENT

Source: National Institute of Corrections and National Center on Institutions and Alternatives, National Study
of Jail Suicides, 2006.

confinement (Fruehwald et al. 2004). No significant differences were found between suicides that
occurred in holding and detention facilities in regard to month and day of the week in which the
suicides took place.

Time of Day
Experts theorize that inmate suicides occur more often when jail staff perform less frequent super­
vision. NCIA’s 1988 study generally supported this theory—project staff found that more than
30 percent of all suicides occurred during the 6 hours between midnight and 6 a.m. Results from
the current study, however, show that almost one-third (31.9 percent) of all suicides occurred dur­
ing the 6 hours between 3:01 and 9 p.m. (see table 15). This is consistent with other recent BJS
data that also found that the frequency of suicides was fairly evenly distributed throughout the day
(Mumola 2005). No significant differences were found between the time of day when suicides
occurred in holding and detention facilities.

Length of Confinement Prior to Suicide
Less than one-quarter (23.4 percent) of all inmates who committed suicide were dead within the
first 24 hours of confinement (see table 16). This is in stark contrast to NCIA’s 1988 study (Hayes
1989), which found that more than 50 percent of victims were dead within the first 24 hours. This

20

National Study of Jail Suicide: 20 Years Later

Table 15. Time of Day When Suicide Occurred in U.S. Jails: 2005–06
FACILITY TYPE
TIME OF
SUICIDE

HOLDING
(0–72 hours)
NUMBER

DETENTION
(>72 hours)

PERCENT

NUMBER

COMBINED

PERCENT

NUMBER

PERCENT

12:01–3 a.m.

8

13.8

55

13.5

63

13.6

3:01–6 a.m.

5

8.6

43

10.6

48

10.3

6:01–9 a.m.

1

1.7

40

9.9

41

8.8

10

17.2

46

11.3

56

12.1

8

13.8

43

10.6

51

11.0

3:01–6 p.m.

10

17.2

65

16.0

75

16.2

6:01–9 p.m.

12

20.7

61

15.0

73

15.7

4

7.0

53

13.1

57

12.3

58

100.0

406

100.0

464

100.0

9:01 a.m.–noon
12:01–3 p.m.

9:01 p.m.–midnight
Total

Source: National Institute of Corrections and National Center on Institutions and Alternatives, National Study
of Jail Suicides, 2006.

current finding, however, is consistent with other recent BJS data regarding length of confinement
prior to suicide (Mumola 2005). In addition, whereas NCIA’s prior study found that 15 percent of
suicides occurred between 2 and 14 days of confinement, the most recent data indicate that 26.6
percent of the deaths occurred during this same period. However, almost half (44.8 percent) of all
inmates who committed suicide in holding facilities in 2005 and 2006 were dead within the first 6
hours of confinement. Although significant, this finding is much lower than NCIA’s 1988 study, which
found that 80 percent of suicides in holding facilities occurred within the first 6 hours (Hayes 1989).
The availability of better screening to identify suicide risk during the initial booking process is
a possible explanation for the variations in time periods prior to suicide between this study and
the earlier study. Another explanation may be increased staff awareness through training that
emphasized the first few hours of confinement as the highest risk period for suicide. Overall, half
(52.3 percent) of all inmates who committed suicide in detention and holding facilities were dead
between 2 days and 4 months of confinement (in contrast to 34.5 percent in NCIA’s 1988 study).

Intoxication
NCIA’s 1988 study found a significant relationship between intoxication and inmate suicide—
60 percent of inmates who committed suicide were under the influence of alcohol, drugs, or both
at the time of their death. In contrast, the recent data show that only 19.6 percent of all inmates
(including 15 percent of detention facility inmates) who committed suicide were intoxicated at the
time of their deaths (see table 17). However, more than 50 percent of inmates who committed sui­
cide in holding facilities were intoxicated at the time of death. This finding is consistent with the

Chapter 3. Demographic Findings of Jail Suicide Data

21

Table 16. Length of Confinement Prior to Suicide in U.S. Jails: 2005–06
FACILITY TYPE
LENGTH OF
CONFINEMENT

HOLDING
(0–72 hours)

DETENTION
(>72 hours)

COMBINED

NUMBER

PERCENT

NUMBER

0–3 hours

14

24.2

23

5.6

37

8.0

4–6 hours

12

20.7

18

4.4

30

6.5

7–9 hours

2

3.4

8

1.9

10

2.1

10–12 hours

1

1.7

11

2.7

12

2.6

13–18 hours

0

0.0

4

0.9

4

0.8

19–24 hours

3

5.2

13

3.2

16

3.4

25–48 hours

5

8.6

40

9.8

45

9.7

11

19.0

112

27.7

123

26.6

15–30 days

1

1.7

25

6.1

26

5.6

1–4 months

4

6.9

89

22.1

93

20.1

5–7 months

1

1.7

29

7.2

30

6.5

8–12 months

0

0.0

15

3.7

15

3.2

>1 year

3

5.2

13

3.2

16

3.4

Unknown

1

1.7

6

1.5

7

1.5

58

100.0

406

100.0

464

100.0

2–14 days

Total

PERCENT

NUMBER

PERCENT

Source: National Institute of Corrections and National Center on Institutions and Alternatives, National Study
of Jail Suicides, 2006.

data in table 16, which indicate that fewer inmates committed suicide within the first 24 hours of
confinement, the most likely time period in which they would have been intoxicated.
Although these findings seem to indicate that most of the inmates who committed suicide were not
intoxicated at the time of their deaths, there remains a strong relationship between intoxication and
suicide. Intoxication acts as a precipitant of suicidal behavior, and has been consistently linked to
impulsive suicides in the general community (Moscicki 2001).

Method, Instrument, and Anchoring Device
The overwhelming majority (92.7 percent) of inmates who committed suicide chose asphyxiation
by hanging as the method (see table 18). No significant differences in the method used were
found between suicides that occurred in holding and detention facilities. This is consistent with find­
ings from NCIA’s 1988 study (Hayes 1989). Methods listed as “other” included self-strangulation and
asphyxiation using a plastic bag.

22

National Study of Jail Suicide: 20 Years Later

Table 17. Intoxication of Suicide Victims in U.S. Jails: 2005–06
FACILITY TYPE
HOLDING
(0–72 hours)

INTOXICATION

DETENTION
(>72 hours)

NUMBER

PERCENT

NUMBER

19

32.7

33

Drugs

8

13.8

Both alcohol and drugs

3

Alcohol

Neither alcohol nor drugs
Unknown
Total

COMBINED

PERCENT

NUMBER

PERCENT

8.1

52

11.2

25

6.2

33

7.1

5.2

3

0.7

6

1.3

21

36.2

307

75.6

328

70.7

7

12.1

38

9.4

45

9.7

58

100.0

406

100.0

464

100.0

Source: National Institute of Corrections and National Center on Institutions and Alternatives, National Study
of Jail Suicides, 2006.

As shown in table 19, two-thirds (66.4 percent) of inmates who committed suicide used their bed­
ding as the instrument. Clothing (other than shoelaces and belts) was used in 15.5 percent of sui­
cides. These findings are in contrast to NCIA’s 1988 study, which found that slightly less than half
(47.9 percent) of the suicides involved bedding and 34 percent involved clothing (Hayes 1989).
Significant differences in regard to the instrument used were found between suicides that occurred
in holding and detention facilities. Clothing (other than shoelaces and belts) was used in 46.5 per­
cent of suicides that occurred in holding facilities, but in only 11.1 percent of those that occurred
in detention facilities. Bedding was used in 71.2 percent of suicides that occurred in detention
facilities, but in only 32.8 percent of those that occurred in holding facilities. It is likely that these
differences, which are consistent with findings from NCIA’s 1988 study (Hayes 1989), occurred
because holding facilities are less likely to confine individuals overnight and therefore make less
use of bedding.
More than half of the inmates who committed suicide by hanging used either the bed/bunk (29.6
percent) or bars or cell door (27.0 percent) as the anchoring device (see table 20). Ventilation
grates were used in 18.2 percent of the deaths; another study on prison suicide found that ventila­
tion grates were used in more than 50 percent of deaths by hanging (He et al. 2001). A recently
released national study on juvenile suicides in confinement found that door knobs and hinges (21
percent), air vent grates (20 percent), bunk frames and holes (20 percent), and window frames
(15 percent) were the anchoring devices used in most suicides that occurred among youth (Hayes
2009). Telephones that have cords of varying length and that are located inside holding and book­
ing cells also have been used in hanging attempts (Hayes 2003; Quinton and Dolinak 2003).
Findings from this study indicate that multiple anchoring devices, however innocuous they may
appear, are routinely available to inmates who attempt to commit suicide by hanging.

Chapter 3. Demographic Findings of Jail Suicide Data

23

Table 18. Method of Suicide in U.S. Jails: 2005–06
FACILITY TYPE
HOLDING
(0–72 hours)

METHOD

NUMBER
Hanging

DETENTION
(>72 hours)

PERCENT

NUMBER

COMBINED

PERCENT

NUMBER

PERCENT

56

96.6

374

92.1

430

92.7

Overdose

1

1.7

5

1.2

6

1.3

Cutting

0

0.0

6

1.5

6

1.3

Jumping

0

0.0

8

2.0

8

1.7

Ingestion of foreign object

0

0.0

2

0.5

2

0.4

Other

1

1.7

11

2.7

12

2.6

Total

58

100.0

406

100.0

464

100.0

Source: National Institute of Corrections and National Center on Institutions and Alternatives, National Study
of Jail Suicides, 2006.

Table 19. Instrument Used in Suicide in U.S. Jails: 2005–06
FACILITY TYPE
HOLDING
(0–72 hours)

INSTRUMENT

DETENTION
(>72 hours)

COMBINED

NUMBER

PERCENT

NUMBER

PERCENT

NUMBER

PERCENT

Bedding

19

32.8

289

71.2

308

66.4

Clothing

27

46.5

45

11.1

72

15.5

Shoelace

7

12.1

12

3.0

19

4.1

Belt

1

1.7

5

1.2

6

1.3

Towel

0

0.0

7

1.7

7

1.5

Razor/knife

0

0.0

5

1.2

5

1.1

Drugs

1

1.7

5

1.2

6

1.3

None

0

0.0

7

1.7

7

1.5

Unknown

3

5.2

31

7.7

34

7.3

58

100.0

406

100.0

464

100.0

Total

Source: National Institute of Corrections and National Center on Institutions and Alternatives, National Study
of Jail Suicides, 2006.

24

National Study of Jail Suicide: 20 Years Later

Time Span Between Last Observation and Finding Victim
Nearly 21 percent of suicide victims were found less than 15 minutes after the last observation,
and 30.8 percent of victims were found more than 1 hour after the last observation (see table 21).
No significant differences were found between suicides that occurred in holding and detention
facilities in regard to time span. This is different from NCIA’s 1988 study, which found that 42.3
percent of victims were found less than 15 minutes after the last observation and only 11.2 percent
were found more than 1 hour after the last observation (Hayes 1989). There is no clear explana­
tion for these differences in time span between the two studies.

Administration of Cardiopulmonary Resuscitation
Almost two-thirds (62.7 percent) of respondents stated that jail staff administered cardiopulmonary
resuscitation (CPR) to the victim before medical personnel arrived (see table 22). Jail staff did not
administer CPR in the remaining cases because they believed the victim was already dead, were
waiting for medical staff to arrive, or did not have training in CPR. This finding is consistent with a
recent study of prison suicides, which found that first responders (usually officers) failed to initiate
life-saving measures in approximately one-third of cases involving suicide (Patterson and Hughes
2008). In addition, only 35.6 percent of respondents stated that jail or medical personnel used
an automated external defibrillator (AED) on the victim. In the majority of cases, staff did not have
access to an AED.

Table 20. Anchoring Device Used in Hanging in U.S. Jails: 2005–06
ANCHORING DEVICE

NUMBER

PERCENT

Bed or bunk

127

29.6

Bars or cell door

116

27.0

Ventilation grate

78

18.2

Shower hardware

16

3.7

Corded telephone

14

3.3

Conduit piping

12

2.8

Light fixture

9

2.1

Window

8

1.8

Shelf/clothing hook

8

1.8

Smoke detector

6

1.3

Other

24

5.6

Unknown

12

2.8

430

100.0

Total

Source: National Institute of Corrections and National Center on Institutions and Alternatives, National Study
of Jail Suicides, 2006.

Chapter 3. Demographic Findings of Jail Suicide Data

25

Table 21. Time Span Between Last Observation and Finding Victim in U.S. Jails: 2005–06
FACILITY TYPE
HOLDING
(0–72 hours)

TIME SPAN

DETENTION
(>72 hours)

COMBINED

NUMBER

PERCENT

NUMBER

PERCENT

NUMBER

PERCENT

<15 minutes

10

17.2

86

21.2

96

20.7

15–30 minutes

12

20.7

91

22.4

103

22.2

30–60 minutes

9

15.5

78

19.2

87

18.8

15

25.9

89

21.9

104

22.4

>3 hours

9

15.5

30

7.4

39

8.4

Unknown

3

5.2

32

7.9

35

7.5

58

100.0

406

100.0

464

100.0

1–3 hours

Total

Source: National Institute of Corrections and National Center on Institutions and Alternatives, National Study
of Jail Suicides, 2006.

Table 22. Administration of Cardiopulmonary Resuscitation (CPR) to Suicide Victims in
U.S. Jails: 2005–06
FACILITY TYPE
CPR
ADMINISTRATION

HOLDING
(0–72 hours)

DETENTION
(>72 hours)

COMBINED

NUMBER

PERCENT

NUMBER

PERCENT

NUMBER

PERCENT

Yes

36

62.1

255

62.8

291

62.7

No

22

37.9

151

37.2

173

37.3

Total

58

100.0

406

100.0

464

100.0

Source: National Institute of Corrections and National Center on Institutions and Alternatives, National Study
of Jail Suicides, 2006.

Housing Assignment
At the time of death, approximately 60 percent of inmates who committed suicide were assigned
to single-occupancy cells and 40 percent were housed in multiple-occupancy cells. Cellmates were
absent from the cells in about two-thirds of the suicides that occurred in multiple-occupancy cells.
No significant differences were found between suicides that occurred in holding and detention
facilities in regard to housing assignment.

26

National Study of Jail Suicide: 20 Years Later

Well over one-third (38.4 percent) of inmates who committed suicide were in isolation or segrega­
tion at the time of their deaths (see table 23), and 29.3 percent of inmates who committed suicide
had a history of being placed in isolation or segregation prior to their deaths. Many more inmates
who committed suicide in detention facilities were in isolation or segregation than inmates who
died in holding facilities (41.1 percent versus 19.0 percent). In contrast, NCIA’s 1988 study found
that 67 percent of the victims were held in isolation at the time of their death (Hayes 1989). A
possible explanation for the decreased use of isolation for inmates who later committed suicide is
increased staff awareness through training that emphasized isolation as a contributing factor to
inmate suicides.

Table 23. Isolation or Segregation at Time of Death for Suicide Victims in U.S. Jails: 2005–06
FACILITY TYPE
ISOLATION/
SEGREGATION

HOLDING
(0–72 hours)

DETENTION
(>72 hours)

COMBINED

NUMBER

PERCENT

NUMBER

PERCENT

NUMBER

Yes

11

19.0

167

41.1

178

38.4

No

47

81.0

236

58.2

283

61.0

0

0.0

3

0.7

3

0.6

58

100.0

406

100.0

464

100.0

Unknown
Total

PERCENT

Source: National Institute of Corrections and National Center on Institutions and Alternatives, National Study
of Jail Suicides, 2006.

Suicide Precautions
Only 7.5 percent of the inmates who committed suicide were on suicide precautions at the time of
their deaths (see table 24). No significant differences were found between suicides that occurred
in holding and detention facilities in regard to suicide precautions. Of the 35 inmates who com­
mitted suicide while on suicide precautions, 6 were being observed at 30-minute intervals, 24 at
15-minute intervals, 1 at 10-minute intervals, and 4 were under constant observation (including
closed-circuit television (CCTV) monitoring). Of the inmates who committed suicide, 29.5 percent
had previously been placed on suicide precautions during their current or previous confinement,
and some of them were removed from this status shortly before their death.

Chapter 3. Demographic Findings of Jail Suicide Data

27

Table 24. Suicide Precaution Status Among Suicide Victims in U.S. Jails: 2005–06
FACILITY TYPE
SUICIDE PRECAUTION
STATUS

HOLDING
(0–72 hours)
NUMBER

DETENTION
(>72 hours)

PERCENT

NUMBER

COMBINED

PERCENT

NUMBER

PERCENT

Yes

4

6.9

31

7.6

35

7.5

No

54

93.1

375

92.4

429

92.5

Total

58

100.0

406

100.0

464

100.0

Source: National Institute of Corrections and National Center on Institutions and Alternatives, National Study
of Jail Suicides, 2006.

There may be several reasons why inmates are able to commit suicide while on suicide precau­
tions: (1) jail staff do not observe the inmate at the required time interval, (2) the inmate is on an
observation level that is not commensurate with the level of risk (e.g., an acutely suicidal inmate
placed on a 15-minute observation level), (3) the inmate is on an observation level that is not con­
sistent with national correctional standards (e.g., a 30-minute interval), (4) CCTV monitoring is not
reliable, and (5) the inmate is placed in a cell that contains anchoring devices that can be used in
a hanging attempt. In fact, because medical experts warn that brain damage from asphyxiation
caused by a suicide attempt can occur within 4 minutes and death can occur within 5 to 6 minutes
(American Heart Association 1992), observation at 10- or 15-minute intervals is only sufficient
under the following conditions—surveillance must be conducted at staggered intervals (e.g., 5
minutes, 10 minutes, 7 minutes) and the cell housing the suicidal inmate must be free of protrusions
(Hayes 2006).

No-Harm Contracts
Mental health clinicians often develop no-harm contracts with potentially suicidal inmates, seeking
assurance that their clients will not engage in self-injurious behavior. Correctional facilities may
also ask each incoming inmate to sign a no-harm letter as a protection against liability. In truth,
however, most legal experts believe that a no-harm contract or letter does not afford legal protec­
tion to a correctional agency or mental health worker. Although no-harm contracts or letters may
be positive in some cases, most clinicians agree that once an inmate becomes acutely suicidal, his
or her written or verbal assurances cannot be taken seriously (Thienhaus and Piasecki 1997).
The survey questionnaire defined a no-harm contract as “a verbal and/or written agreement
between the inmate and facility staff/clinician in which the inmate provides assurances they will
not commit suicide or engage in self-injurious behavior.” Table 25 shows that 12.7 percent of
the inmates who committed suicide stated that they would not commit suicide or engage in selfinjurious behavior, thus casting significant doubt as to the usefulness of such a contract.

28

National Study of Jail Suicide: 20 Years Later

Table 25. No-Harm Contracts Used in U.S. Jails: 2005–06
FACILITY TYPE
NO-HARM
CONTRACTS

HOLDING
(0–72 hours)
NUMBER

DETENTION
(>72 hours)

PERCENT

COMBINED

NUMBER

PERCENT

NUMBER

PERCENT

Yes

1

1.7

58

14.3

59

12.7

No

51

87.9

317

78.1

368

79.3

6

10.4

31

7.6

37

8.0

58

100.0

406

100.0

464

100.0

Unknown
Total

Source: National Institute of Corrections and National Center on Institutions and Alternatives, National Study
of Jail Suicides, 2006.

Assessment by a Qualified Mental Health Professional
The survey questionnaire defined a qualified mental health professional (QMHP) as “an individual
by virtue of their education, credentials, and experience that is permitted by law to evaluate and
care for the mental health needs of patients. May include, but is not limited to, a psychiatrist,
psychologist, clinical social worker, and psychiatric nurse.” Table 26 shows that 37.1 percent of
inmates who committed suicide were assessed by a QMHP prior to their deaths. Because holding
facilities do not usually have QMHP staff, significant differences were found between suicides that
occurred in holding and detention facilities in regard to a QMHP assessment; a much higher per­
centage of suicide victims in detention facilities were seen by a QMHP prior to their deaths.

Table 26. Qualified Mental Health Professional (QMHP) Assessment of Suicide Victims in
U.S. Jails: 2005–06
FACILITY TYPE
QMHP
ASSESSMENT

HOLDING
(0–72 hours)

DETENTION
(>72 hours)

COMBINED

NUMBER

PERCENT

NUMBER

PERCENT

NUMBER

PERCENT

Yes

10

17.2

162

39.9

172

37.1

No

46

79.4

217

53.4

263

56.6

2

3.4

27

6.7

29

6.3

58

100.0

406

100.0

464

100.0

Unknown
Total

Source: National Institute of Corrections and National Center on Institutions and Alternatives, National Study
of Jail Suicides, 2006.

Chapter 3. Demographic Findings of Jail Suicide Data

29

Among inmates who committed suicide and received a QMHP assessment prior to their deaths,
almost half (47 percent) had been assessed within 3 days before their death (see table 27). No
significant differences were found between suicides that occurred in holding and detention facilities
in regard to last contact with a QMHP.
Inmates on suicide precautions should be assessed daily for suicide risk (Hayes 2005; National
Commission on Correctional Health Care 2008); however, of the 35 inmates on suicide precau­
tions at the time of their deaths, only 20 percent had been seen by a QMHP within the previous
24 hours.

Table 27. Suicide Victims’ Last Contact With a Qualified Mental Health Professional (QMHP) in
U.S. Jails: 2005–06
LAST CONTACT WITH QMHP

NUMBER

PERCENT

<1 day

34

19.7

1–3 days

47

27.3

4–6 days

13

7.6

7–13 days

15

8.8

14–30 days

18

10.4

1–2 months

16

9.4

3–4 months

4

2.3

5–6 months

5

2.9

7–9 months

1

0.6

>1 year

1

0.6

18

10.4

172

100.0

Unknown
Total

Source: National Institute of Corrections and National Center on Institutions and Alternatives, National Study
of Jail Suicides, 2006.

Court Hearing, Telephone Call, and/or Visit Prior to Suicide
Although the possible relationship between an inmate suicide and a court hearing, telephone call,
and/or visit has not received considerable attention in recent prior research efforts, one earlier
study found that approximately 50 percent of suicides in a large urban jail system occurred within
3 days of a court hearing (Marcus and Alcabes 1993). Approximately one-third (34.5 percent) of
the inmates who committed suicide attended (or were scheduled to attend) a court hearing close to
the date of their deaths (see table 28).
The vast majority (80 percent) of the inmates who committed suicide attended (or were scheduled
to attend) a court hearing within 2 days of when they committed suicide (see table 29). No

30

National Study of Jail Suicide: 20 Years Later

Table 28. Suicides Occurring Close to Date of Court Hearing in U.S. Jails: 2005–06
FACILITY TYPE
SUICIDE AND
COURT
HEARING

HOLDING
(0–72 hours)

DETENTION
(>72 hours)

COMBINED

NUMBER

PERCENT

NUMBER

PERCENT

NUMBER

PERCENT

Yes

15

25.8

145

35.8

160

34.5

No

39

67.3

207

50.9

246

53.0

4

6.9

54

13.3

58

12.5

58

100.0

406

100.0

464

100.0

Unknown
Total

Source: National Institute of Corrections and National Center on Institutions and Alternatives, National Study
of Jail Suicides, 2006.

Table 29. Suicides Occurring Close to a Scheduled Court Hearing in U.S. Jails: 2005–06
SCHEDULED COURT HEARING

NUMBER

PERCENT

<1 day

39

24.3

1–2 days

89

55.7

3–7 days

32

20.0

160

100.0

Total

Source: National Institute of Corrections and National Center on Institutions and Alternatives, National Study
of Jail Suicides, 2006.

significant differences were found in regard to attendance at a court hearing between suicides that
occurred in holding and detention facilities.
Only 21.8 percent of the inmates who committed suicide received a telephone call and/or visit
close to the date of their deaths (see table 30). The vast majority (approximately 80 percent) of
the events were telephone calls. This variable received nearly 46 percent of “unknown” responses.
Approximately two-thirds (67.3 percent) of the inmates who committed suicide and received a
telephone call and/or visit died less than 24 hours after the event (see table 31). No significant
differences were found between suicides that occurred in holding and detention facilities in regard
to receiving a telephone call or visit.
A significant number of respondents answered “unknown” to survey questions regarding the proximity
of the suicide to a court hearing, telephone call, and/or visit. Based on the author’s experience in
reviewing inmate suicide cases and mortality reviews, it is likely that these relationships would be
proved stronger if jails kept appropriate records.

Chapter 3. Demographic Findings of Jail Suicide Data

31

Table 30. Suicides Occurring Close to a Telephone Call or Visit in U.S. Jails: 2005–06
FACILITY TYPE
TELEPHONE CALL
OR VISIT

HOLDING
(0–72 hours)
NUMBER

DETENTION
(>72 hours)

COMBINED

PERCENT

NUMBER

PERCENT

NUMBER

PERCENT

Yes

16

27.6

85

20.9

101

21.8

No

24

41.4

127

31.3

151

32.5

Unknown

18

31.0

194

47.8

212

45.7

Total

58

100.0

406

100.0

464

100.0

Source: National Institute of Corrections and National Center on Institutions and Alternatives, National Study
of Jail Suicides, 2006.

Table 31. Suicides Occurring Close to a Scheduled Telephone Call or Visit in U.S. Jails: 2005–06
RECEIPT OF TELEPHONE CALL OR VISIT

NUMBER

PERCENT

<1 day

68

67.3

1–2 days

10

9.9

3–7 days

3

3.0

20

19.8

101

100.0

Unknown (but within 7 days)
Total

Source: National Institute of Corrections and National Center on Institutions and Alternatives, National Study
of Jail Suicides, 2006.

Characteristics of the Jail Facilities
Type, Administration, Population, and Capacity
As stated previously, data were received from 406 detention facilities and 58 holding facilities.
County governments administered the vast majority (83.9 percent) of facilities that experienced
suicides, followed by municipal governments (12.8 percent), private agencies (1.8 percent), and
state or regional governments (1.5 percent). The average population of most detention facilities
that sustained suicides was about 550 inmates, whereas holding facilities averaged 5 inmates.
Approximately 70 percent of the facilities that experienced suicides were at or under capacity
at the time of the inmate suicide, suggesting that overcrowding was not a contributing factor to
the deaths.

32

National Study of Jail Suicide: 20 Years Later

Identification and/or Screening for Suicide Risk
A correctional facility’s suicide prevention efforts must include the screening and assessment of
inmates when they enter the facility (Hayes 2005; National Commission on Correctional Health
Care 2008). Although mental health and medical communities agree that no single set of risk fac­
tors can predict suicide, there is little disagreement about the value of screening and assessment in
preventing suicide (Cox and Morschauser 1997; Hughes 1995). Intake screening for all inmates
and ongoing assessment of at-risk inmates are critical because research consistently reports that
at least two-thirds of suicide victims communicate their intent some time before death, and that an
individual with a history of one or more suicide attempts is at a much higher risk for suicide than
one who has never made an attempt (Clark and Horton-Deutsch 1992; Maris 1992). Although ide­
ation, prior attempt(s), and/or other forms of suicidal behavior indicate current risk, other factors
such as a recent significant loss, limited prior incarceration, lack of social support system, and vari­
ous stressors of confinement can also be strongly related to suicide (Bonner 1992). Intake screen­
ing should include not only questions about current suicidal ideation and prior suicidal behavior,
but also questions about the inmate’s suicide risk during any prior confinement in the facility and
the arresting and/or transporting officer(s)’ belief that the inmate is currently at risk (Hayes 2005;
National Commission on Correctional Health Care 2008).
Table 32 shows that the vast majority (77.1 percent) of respondents reported that they maintained an
intake screening process to identify inmates’ suicide risk when they entered the facility; holding facili­
ties screened for suicide risk to a lesser degree (63.7 percent) than detention facilities (79.1 percent).
However, only 27.4 percent of respondents reported that the intake screening process included
verification as to whether the newly arrived inmate was on suicide precautions during any prior
confinement in the jail facility (see table 33).

Table 32. Intake Screening for Suicide Risk in U.S. Jails: 2005–06
FACILITY TYPE
INTAKE SCREENING
FOR SUICIDE RISK

HOLDING
(0–72 hours)

DETENTION
(>72 hours)

COMBINED

NUMBER

PERCENT

NUMBER

PERCENT

NUMBER

PERCENT

Yes

37

63.7

321

79.1

358

77.1

No

21

36.3

85

20.9

106

22.9

Total

58

100.0

406

100.0

464

100.0

Source: National Institute of Corrections and National Center on Institutions and Alternatives, National Study
of Jail Suicides, 2006.

Chapter 3. Demographic Findings of Jail Suicide Data

33

In addition, only 30.6 percent of respondents reported that the intake screening process included
verification as to whether the arresting and/or transporting officer(s) believed that the newly
arrived inmate was at risk for suicide (see table 34).

Table 33. Verification of Suicide Risk During Prior Confinement in U.S. Jails: 2005–06
FACILITY TYPE
SUICIDE RISK DURING
PRIOR CONFINEMENT

HOLDING
(0–72 hours)

DETENTION
(>72 hours)

COMBINED

NUMBER

PERCENT

NUMBER

PERCENT

NUMBER

PERCENT

Yes

15

25.9

112

27.6

127

27.4

No

43

74.1

294

72.4

337

72.6

Total

58

100.0

406

100.0

464

100.0

Source: National Institute of Corrections and National Center on Institutions and Alternatives, National Study
of Jail Suicides, 2006.

Table 34. Arresting and/or Transporting Officer Opinion About Suicide Risk in U.S. Jails: 2005–06

ARRESTING AND/OR
TRANSPORTING
OFFICER OPINION
ABOUT SUICIDE RISK

FACILITY TYPE
HOLDING
(0–72 hours)

DETENTION
(>72 hours)

COMBINED

NUMBER

PERCENT

NUMBER

PERCENT

NUMBER

PERCENT

Yes

18

31.0

124

30.6

142

30.6

No

40

69.0

282

69.4

322

69.4

Total

58

100.0

406

100.0

464

100.0

Source: National Institute of Corrections and National Center on Institutions and Alternatives, National Study
of Jail Suicides, 2006.

Thus, although a high percentage of facilities that sustained inmate suicides had a screening pro­
cess to identify potentially suicidal behavior at intake, the process was flawed in that most facilities
did not verify whether the newly arrived inmate was on suicide precautions during any prior con­
finement in the jail facility, nor whether the arresting and/or transporting officer(s) believed that the
inmate was at risk for suicide.

Suicide-Prevention Training
The essential component in any suicide prevention program is properly trained correctional staff,
who form the backbone of any jail or prison facility. Very few suicides are actually prevented by

34

National Study of Jail Suicide: 20 Years Later

mental health, medical, or other professional staff because suicides usually take place in inmate
housing units, often during late evening hours or on weekends when inmates are generally outside
the purview of program staff. Therefore, correctional staff who have been trained in suicideprevention techniques and have developed an intuitive sense about the inmates under their care
must prevent these incidents. In addition, correctional officers are often the only staff available
24 hours a day and thus form the front line of defense in preventing suicides. However, as with
medical and mental health personnel, correctional staff cannot detect, assess, or prevent a suicide
without training. Lives are lost and jurisdictions incur unnecessary liability from these deaths when
administrators fail to create and maintain effective training programs (Cohen 2008; Hayes 2005).
Table 35 shows that the majority (61.8 percent) of respondents reported that they had provided
suicide-prevention training to at least 90 percent of their correctional staff, although holding facili­
ties provided far less training (48.3 percent) than detention facilities (63.7 percent).

Table 35. Suicide-Prevention Training in U.S. Jails: 2005–06
FACILITY TYPE
SUICIDE-PREVENTION
TRAINING

HOLDING
(0–72 hours)

DETENTION
(>72 hours)

NUMBER

PERCENT

Yes

28

48.3

No

30

Total

58

NUMBER

COMBINED

PERCENT

NUMBER

PERCENT

259

63.7

287

61.8

51.7

147

36.3

177

38.2

100.0

406

100.0

464

100.0

Source: National Institute of Corrections and National Center on Institutions and Alternatives, National Study
of Jail Suicides, 2006.

Of the respondents who reported suicide-prevention training, 74.9 percent stated that the training
took place yearly. The remainder (25.1 percent) reported that training took place either biennially
or on a preservice basis. Holding facilities provided far less annual training (32.2 percent) than
detention facilities (79.5 percent). Further, only 6 percent of all reported suicide-prevention training
was 8 hours in length. The majority (69 percent) of training was 2 hours or less. No significant dif­
ferences were found between suicides that occurred in holding and detention facilities in regard to
the duration of suicide-prevention training.
The combined data in tables 35 and 36 indicate that almost two-thirds (63.3 percent) of all facili­
ties that sustained a suicide either did not provide suicide-prevention training or did not provide
the training annually.

Chapter 3. Demographic Findings of Jail Suicide Data

35

Table 36. Frequency of Suicide-Prevention Training in U.S. Jails: 2005–06
FACILITY TYPE
FREQUENCY OF
SUICIDE-PREVENTION
TRAINING

HOLDING
(0–72 hours)

DETENTION
(>72 hours)

COMBINED

NUMBER

PERCENT

NUMBER

PERCENT

NUMBER

PERCENT

Yearly

9

32.2

206

79.5

215

74.9

Other

19

67.8

53

20.5

72

25.1

Total

28

100.0

259

100.0

287

100.0

Source: National Institute of Corrections and National Center on Institutions and Alternatives, National Study
of Jail Suicides, 2006.

CPR Certification
Following a suicide attempt, the victim’s chances for survival depend on both the level and prompt­
ness of staff intervention. According to most national correctional standards and practices, a facil­
ity’s emergency response policy should require all staff to be trained in CPR procedures. The vast
majority (80.3 percent) of respondents reported providing CPR training to their correctional staff
(see table 37); holding facilities provided slightly less training (70.7 percent) than detention facili­
ties (81.7 percent). Almost two-thirds (62.7 percent) of respondents stated that their jail staff admin­
istered CPR to the victim before medical personnel arrived (see table 22, page 26).

Table 37. Certification in Cardiopulmonary Resuscitation (CPR) in U.S. Jails That Sustained
a Suicide: 2005–06
FACILITY TYPE
HOLDING
(0–72 hours)

CPR CERTIFICATION

DETENTION
(>72 hours)

COMBINED

NUMBER

PERCENT

NUMBER

PERCENT

NUMBER

PERCENT

Yes

41

70.7

332

81.7

373

80.3

No

17

29.3

74

18.3

91

19.7

Total

58

100.0

406

100.0

464

100.0

Source: National Institute of Corrections and National Center on Institutions and Alternatives, National Study
of Jail Suicides, 2006.

Suicide Watch and Levels of Observation
National correctional standards and practices recommend two levels of supervision for suicidal
inmates: close observation and constant observation (Hayes 2005; National Commission on
Correctional Health Care 2008). Close observation is appropriate for an inmate who is not active­
ly suicidal, but who expresses suicidal ideation and/or has a recent prior history of self-harming
behavior. Staff should observe these inmates at staggered intervals not to exceed every 10 minutes

36

National Study of Jail Suicide: 20 Years Later

(e.g., 5 minutes, 10 minutes, 7 minutes). Constant observation is appropriate for an inmate who
is actively suicidal (i.e., either threatening or engaging in suicidal behavior). Staff should observe
these inmates on a continuous, uninterrupted basis. In some jurisdictions, staff use an intermediate
level of observation that involves monitoring at staggered intervals that do not exceed 5 minutes.
Other aids (e.g., CCTV, inmate companions, or observers) can be used as a supplement to, but
never as a substitute for, these observation levels.
Table 38 shows that the overwhelming majority (92.7 percent) of respondents reported that they
maintained a suicide watch10 protocol (apart from CCTV or an inmate companion11) to provide
staff observation of inmates identified as suicidal; holding facilities had such a process to a far
lesser degree (69.0 percent) than detention facilities (96.1 percent). One reason why holding
facilities reported a lower percentage for suicide watch protocol could be their traditional reliance
on CCTV.

Table 38. Suicide Watch Protocol in U.S. Jails: 2005–06
FACILITY TYPE
SUICIDE WATCH
PROTOCOL

HOLDING
(0–72 hours)

DETENTION
(>72 hours)

COMBINED

NUMBER

PERCENT

NUMBER

PERCENT

NUMBER

PERCENT

Yes

40

69.0

390

96.1

430

92.7

No

18

31.0

16

3.9

34

7.3

Total

58

100.0

406

100.0

464

100.0

Source: National Institute of Corrections and National Center on Institutions and Alternatives, National Study
of Jail Suicides, 2006.

In addition, although the vast majority of facilities had a suicide watch protocol, only 1.7 percent
of respondents reported that constant observation was an option for supervising suicidal inmates.
The vast majority (87.2 percent) of inmates on suicide watch were required to be closely observed
at 15-minute intervals. No significant differences were found between suicides that occurred in
holding and detention facilities in regard to the levels of observation provided to suicidal inmates.
Slightly more than half (51.2 percent) of the respondents reported that only mental health person­
nel were authorized to downgrade and discharge inmates from suicide watch (see table 39). In
approximately one-quarter (25.4 percent) of the facilities, either medical or mental health person­
nel were authorized to downgrade and discharge inmates from suicide watch. In a small number
(2.2 percent) of facilities, inmates could only be removed from suicide watch when they were
released from custody. Significant differences were found between holding and detention
10

For purposes of the survey, “suicide watch” was defined as “the level(s) of direct visual observation by staff that is given to an
inmate identified as being at risk of suicide. Excludes closed circuit television, inmate companions/inmate observation aide, or
any other non-staff monitoring.”

11

For purposes of the survey, “inmate companion” was defined as “a designation by which another inmate is entrusted with the
responsibility of providing observation to an inmate on suicide watch.”

Chapter 3. Demographic Findings of Jail Suicide Data

37

Table 39. Authorization To Discharge Inmates From Suicide Watch in U.S. Jails: 2005–06
FACILITY TYPE
AUTHORIZATION TO
DISCHARGE FROM
SUICIDE WATCH

HOLDING
(0–72 hours)

DETENTION
(>72 hours)

NUMBER

PERCENT

40

68.9

3

0.7

43

9.3

Medical

6

10.3

25

6.1

31

6.7

Mental health

0

0.0

238

58.6

238

51.2

Medical or mental health

3

5.2

115

28.3

118

25.4

All

1

1.8

23

5.7

24

5.2

None

8

13.8

2

0.6

10

2.2

Total

58

100.0

406

100.0

464

100.0

Correctional

NUMBER

COMBINED

PERCENT

NUMBER

PERCENT

Source: National Institute of Corrections and National Center on Institutions and Alternatives, National Study
of Jail Suicides, 2006.

facilities—most holding facilities (68.9 percent) permitted correctional personnel to downgrade and
discharge inmates from suicide watch, presumably because these facilities lacked medical and/or
mental health personnel. Holding facilities were also more likely to remove inmates from suicide watch
only when they were released from custody.

Safe Housing
Inmates placed on suicide precautions are frequently housed in unsafe cells containing protrusions
(i.e., anchoring devices) that could be used to commit suicide by hanging (Hayes 2005; National
Commission on Correctional Health Care 2008). It is well established that hanging is the method
of choice in the overwhelming majority of inmate suicides (Hayes 1989). Although it is impossible
to create a “suicide-proof” cell environment in any correctional facility, it is possible to ensure that
any cell housing a potentially suicidal inmate is free of all obvious protrusions (Atlas 1989; Hayes
2006). Decisions about the location of cells designated to house suicidal inmates should be based
on the ability to maximize staff interaction with those inmates. When possible, suicidal inmates
should be housed in the general population unit, mental health unit, or medical infirmary, if avail­
able, but they should always be located close to staff. As a federal appeals court once stated, “It
is true that prison officials are not required to build a suicide-proof jail. By the same token, how­
ever, they cannot equip each cell with a noose” (Tittle v. Jefferson County Commission 1992).
Two-thirds (67.9 percent) of respondents reported that they did not maintain a protocol by which
suicidal inmates would be assigned to a safe, suicide-resistant, and protrusion-free cell (see
table 40). No significant differences were found between holding and detention facilities in
regard to the safe housing of suicidal inmates.

38

National Study of Jail Suicide: 20 Years Later

Table 40. Safe Housing for Suicidal Inmates in U.S. Jails: 2005–06
FACILITY TYPE
SAFE HOUSING FOR
SUICIDAL INMATES

HOLDING
(0–72 hours)

DETENTION
(>72 hours)

NUMBER

PERCENT

NUMBER

Yes

16

27.6

133

No

42

72.4

Total

58

100.0

COMBINED

PERCENT

NUMBER

PERCENT

32.8

149

32.1

273

67.2

315

67.9

406

100.0

464

100.0

Source: National Institute of Corrections and National Center on Institutions and Alternatives, National Study
of Jail Suicides, 2006.

Mortality Review Process
Every completed suicide, as well as attempts that require hospitalization, should be examined
through a morbidity-mortality review process (Hayes 2005, 2007; National Commission on
Correctional Health Care 2008). If resources permit, a clinical review through a psychological
autopsy is also recommended (Aufderheide 2000; Sanchez 2006). Ideally, an outside agency
should coordinate the morbidity-mortality review to ensure impartiality. The review (separate from
other formal investigations that may be required to determine the cause of death) should include a
critical inquiry of the circumstances surrounding the incident, procedures relevant to the incident,
all relevant training that involved staff received, pertinent medical and mental health services or
reports involving the victim, precipitating factors that may have led to the suicide, and any recom­
mendations for changes involving policy, training, the physical plant, medical or mental health
services, and operational procedures.
Table 41 shows that the majority (62.9 percent) of respondents reported that they did not conduct
a mortality review following the inmate suicide.12 No significant differences were found between
suicides that occurred in holding and detention facilities in regard to the mortality review process,
although holding facilities were slightly less likely to conduct a review.
Survey respondents were also asked whether any possible precipitating factors (i.e., circumstances
that may have caused the victim to commit suicide) were uncovered during the mortality review
process. Although mortality reviews were not conducted in most cases, when they did occur,
respondents either did not cite any precipitating factors or cited possible factors such as a recent
conviction or sentence, fear of transfer to the state prison system, frustration or anger regarding
release, death of a family member or friend, lack of family visitation, and ending of a relationship.
In addition, several respondents reported poor communication among staff and/or inadequate
observation by correctional officers as precipitating factors in the suicides.

12 For purposes of the survey, a “mortality review” was defined as “an interdisciplinary committee process comprised of cor­
rectional, medical, and mental health personnel that examines the events surrounding the death to determine if the incident was
preventable. The review process may include recommendations aimed at reducing the opportunity of future deaths.”

Chapter 3. Demographic Findings of Jail Suicide Data

39

Table 41. Mortality Review Process in U.S. Jails: 2005–06
FACILITY TYPE
MORTALITY REVIEW
PROCESS

HOLDING
(0–72 hours)

DETENTION
(>72 hours)

COMBINED

NUMBER

PERCENT

NUMBER

PERCENT

NUMBER

PERCENT

Yes

16

27.6

148

36.5

164

35.3

No

42

72.4

250

61.6

292

62.9

0

0.0

8

1.9

8

1.8

58

100.0

406

100.0

464

100.0

Unknown
Total

Source: National Institute of Corrections and National Center on Institutions and Alternatives, National Study
of Jail Suicides, 2006.

Finally, respondents were asked whether the mortality review process resulted in any recommen­
dations for corrective action to reduce the likelihood of future suicides. For the cases in which the
reviews occurred, respondents either did not cite any recommendations for corrective action or
cited actions such as staff being reassigned or fired, increased staff training, revision of the suicide
watch process, and revision of the intake screening process.

Written Suicide-Prevention Policy
The literature is replete with examples of how jail and prison systems have developed effective
suicide-prevention programs (Cox and Morschauser 1997; Goss et al. 2002; Hayes 1995, 1998;
White and Schimmel 1995). New York experienced a significant drop in the number of jail sui­
cides following the implementation of a statewide comprehensive prevention program (Cox and
Morschauser 1997). Texas saw a 50-percent decrease in the number of county jail suicides and
nearly a sixfold decrease in the rate of these suicides from 1986 through 1996; much of it can
be attributed to increased staff training and a state requirement for jails to maintain suicideprevention policies (Hayes 1996). One researcher reported no suicides during a 7-year period in
a large county jail after suicide-prevention policies were developed based on the following prin­
ciples: screening; psychological support; close observation; removal of dangerous items from cells;
clear and consistent procedures; and diagnosis, treatment, and transfer of suicidal inmates to the
hospital as necessary (Felthous 1994).
The American Correctional Association (ACA), American Psychiatric Association (APA), and
National Commission on Correctional Health Care (NCCHC) are advocates for comprehensive sui­
cide prevention programs. These organizations have promulgated national correctional standards
that are adaptable to individual jail, prison, and juvenile facilities. Although the ACA standards
are the most widely recognized throughout the country, they provide limited guidance about sui­
cide prevention and simply state that institutions should have a written prevention policy that is

40

National Study of Jail Suicide: 20 Years Later

reviewed by medical or mental health staff. ACA’s broad focus on the operation and administra­
tion of correctional facilities precludes these standards from containing needed specificity. Both
the APA and NCCHC standards, however, are much more instructive and offer the following rec­
ommendations for a suicide prevention program: identification, training, assessment, monitoring,
housing, referral, communication, intervention, notification, reporting, review, and critical incident
debriefing (American Psychiatric Association 2000; National Commission on Correctional Health
Care 2008).
Table 42 shows that the vast majority (84.9 percent) of survey respondents reported that their
facilities maintained a written suicide-prevention policy at the time of the suicide, although holding
facilities maintained policies to a lesser degree (70.7 percent).

Table 42. Written Suicide-Prevention Policy in U.S. Jails: 2005–06
FACILITY TYPE
WRITTEN SUICIDEPREVENTION
POLICY

HOLDING
(0–72 hours)

DETENTION
(>72 hours)

COMBINED

NUMBER

PERCENT

NUMBER

PERCENT

NUMBER

PERCENT

Yes

41

70.7

353

86.9

394

84.9

No

17

29.3

53

13.1

70

15.1

Total

58

100.0

406

100.0

464

100.0

Source: National Institute of Corrections and National Center on Institutions and Alternatives, National Study
of Jail Suicides, 2006.

However, as stated previously, the quality of the written policies for suicide prevention is question­
able. For example, although many respondents reported that their facilities maintained an intake
screening process to identify the suicide risk of inmates entering the facility, in most facilities the
process did not include verification as to whether the arresting and/or transporting officer(s)
believed that the newly arrived inmate was at risk for suicide, nor whether the inmate was at risk
for suicide during prior confinement. In addition, although the majority of respondents reported
that staff in their facilities received suicide-prevention training, most of the training was 2 hours
or less in duration. Most surveyed facilities had a suicide watch protocol, but few provided con­
stant observation. Further, only one-third of respondents reported the availability of protrusion-free
housing for suicidal inmates, and most did not provide a mortality review following an inmate
suicide. These findings are consistent with a national survey on juvenile suicide in confinement indi­
cating that although the vast majority of facilities had a written suicide-prevention policy, only 20
percent had written policies encompassing all of the components of a suicide-prevention program
(Hayes 2009).

Chapter 3. Demographic Findings of Jail Suicide Data

41

Chapter 4. Special Considerations

The Changing Face of Jail Suicide
The National Center on Institutions and Alternatives’ (NCIA’s) 1981 and 1988 national studies of
jail suicide found that, despite a 7-year time interval, demographic data on inmate suicides did not
change dramatically. Most of the key characteristics of jail suicide—offense, intoxication, method
and instrument, isolation, and length of confinement—remained constant over time (Hayes 1989).
Twenty years later, this national study of jail suicides found substantial changes in the demographic
characteristics of inmates who committed suicide during 2005–06. Table 43 shows that some of these

Previously, more than half

changes are stark. For example, suicide victims once characterized as being confined on “minor other”

of all jail suicide victims

offenses were most recently confined on “personal and/or violent” charges. Intoxication was previously

were dead within the first

viewed as a leading precipitant to inmate suicide, yet recent data indicate that it is now found in only

24 hours of confinement;

a minority of cases. Previously, more than half of all jail suicide victims were dead within the first 24

current data suggest that

hours of confinement; current data suggest that less than one-quarter of all victims commit suicide during

less than one-quarter of

this time period, with an equal number of deaths occurring between 2 and 14 days of confinement. In

all victims commit suicide

addition, it appears that inmates who committed suicide were far less likely to be housed in isolation

during this time period, with

than previously reported, yet for unknown reasons it was less likely that they would be found within

an equal number of deaths

15 minutes of the last observation by staff. Finally, more jail facilities that experienced inmate suicides

occurring between 2 and 14

had both written suicide-prevention policies and an intake screening process to identify suicide risk than

days of confinement.

in previous years, although the comprehensiveness of programming remains questionable.

Jail Suicide Rates
Suicide continues to be a leading cause of death among inmates in the nation’s jails. However, a
simple question that is routinely asked—“Aside from the number of deaths, what is the jail suicide rate
throughout the country?”—often evokes controversy (Lester and Yang 2008; Metzner 2002; O’Toole
2008). Suicide rates are calculated using either average daily population (ADP) or yearly admission
data. Many jail administrators would argue that the suicide rate should be calculated based on the total
number of inmates who pass through a facility each year, suggesting that each of them is at potential
risk of suicide and should be counted. A suicide rate calculated according to yearly admissions would
result in a much lower number. For example, few would argue that there would be cause for concern
if a 2,000-bed jail experienced 3 inmate suicides during the course of 12 months. If yearly admissions
were used to calculate the suicide rate of this jail, and approximately 17,000 inmates passed through
the facility each year,13 the rate would be 17.6 deaths per 100,000 inmates. If, however, the ADP was
used to calculate the suicide rate, the rate would be 150 deaths per 100,000 inmates.
13

Based on an actual example.

Chapter 4. Special Considerations

43

Table 43. Changing Face of Suicide in U.S. Jails: 1985–86 to 2005–06
VARIABLE

1985–86

2005–06

Facility type

70% detention

88% detention

Race

72% white

67% white

Gender

94% male

93% male

Age

30

35

Marital status

52% single

42% single

Most serious charge

29% minor other

43% personal and/or violent

Jail status

89% detained

91% detained

Intoxication at death

60%

20%

Time of suicide

30% between midnight and 6 a.m.

32% between 3:01 and 9 p.m.

Length of confinement

51% within first 24 hours

23% within first 24 hours

Method

94% hanging

93% hanging

Instrument

48% bedding

66% bedding

Time span between last
observation and finding victim

42% found within15 minutes

21% found within15 minutes

Isolation

67%

38%

Known history of suicidal
behavior

16%

34%

Known history of mental illness

19%

38%

Intake screening for suicide risk

30%

77%

Written suicide-prevention
policy

51%

85%

Source: National Institute of Corrections and National Center on Institutions and Alternatives, National Study
of Jail Suicides, 2006.

44

National Study of Jail Suicide: 20 Years Later

Historically, suicide rates have been calculated using the ADP. Experts in methodology would
argue that yearly admission data are often unreliable (Mumola 2005) and, because the vast
majority of individuals spend considerably less time in jail during the year than in the community,
it is more appropriate to use the ADP. As previously discussed, the Bureau of Justice Statistics (BJS)
has been collecting and analyzing limited inmate suicide data pursuant to the Death in Custody
Reporting Act of 2000. Although BJS calculations of suicide rates have previously been based
on the ADP, BJS apparently was sensitive to the controversy when it recently wrote that “BJS has
usually based jail mortality rates on the average daily population of inmates (an ADP of under
700,000). A more sensitive measure of jail mortality would reflect the far larger number of admis­
sions into these facilities over the entire year (nearly 13 million). All of these persons admitted
are at risk of dying while held in jail” (Mumola 2005:5). BJS began collecting annual admission
data on the 50 largest jails “to calculate an at-risk measure of mortality” and found the ADP-based
suicide rate for these jurisdictions (29 per 100,000) was 14 times the at-risk suicide rate (2 per
100,000) (Mumola 2005). However, BJS still uses ADP data to calculate the overall suicide rate
of jails (excluding holding facilities) throughout the country. According to the most recent BJS data,
the suicide rate in jails during 2006 was 36 deaths per 100,000 inmates. These data also suggest
that the jail suicide rate has been in decline since the reporting program began in 2000 (Mumola
and Noonan 2008).
It is important to compare jail suicide rates with the suicide rate in the general population. The
Centers for Disease Control and Prevention (CDC) uses general population statistics (not data
based on yearly admission or entry into the United States) to calculate the suicide rate in the com­
munity each year. Thus, to compare the rate of suicide in jail to that in the community, the ADP
must be used. The most recent CDC data calculate the suicide rate in the community at 11 deaths
per 100,000 citizens (Heron et al. 2009). Based on these data, the jail suicide rate (as calculated
by BJS) is approximately three times greater than that in the general population in the community.
There are several reasons for the higher rate of suicide in jail. Jail environments are conducive
to suicidal behavior and an individual entering a jail is at increased risk of facing a crisis situa­
tion. From an inmate’s perspective, certain features of the jail environment may enhance suicidal
behavior: fear of the unknown, distrust of an authoritarian environment, perceived lack of control
over the future, isolation from family and significant others, the shame of being incarcerated, and
the perceived dehumanizing aspects of incarceration. In addition, certain factors that are common
among inmates facing a crisis situation could predispose them to suicide: recent excessive use of
alcohol and/or drugs, recent loss of stabilizing resources, severe guilt or shame over the alleged
offense, current mental illness, prior history of suicidal behavior, and approaching court date.
Some inmates simply are (or become) ill equipped to handle the common stresses of confinement.
Some have argued that jail populations are biased in a number of ways that affect and, perhaps,
distort suicide rates. One theorist stated that: “Two of the primary problems that make jails high
suicide risk points are their unusual population and the high cyclic rate or the total number of peo­
ple exposed to a jail in the course of a year” (Stone 1987:84), arguing that there are certain vari­
ables (including sex, age, marital status, occupational status, and alcoholism) that relate to suicide

Chapter 4. Special Considerations

45

in the general population that are predominantly found in jails and, therefore, make such environ­
ments more suicide prone. In addition, the jail suicide rate “is affected by the ‘cyclic rate’…. What
is occurring in jails is that large numbers of a very suicide-prone population are submitted to short
periods of stay. You might say that our jails are ‘testing’ the suicide potential of a suicide prone
group” (Stone 1987:84).
Despite this possible distortion, the examination of suicide rate comparisons enhances our under­
standing of the jail suicide problem. The 1988 national study of jail suicides calculated 107
suicides per 100,000 inmates in detention facilities in 1986 (based on the ADP in those facili­
ties); that rate was approximately 9 times greater than the rate in the general population (Hayes
1989).14 NCIA’s most recent national study of jail suicide identified 288 suicides that occurred
in detention facilities in 2006. Based on these data, and using the BJS methodology indicating a
The increased awareness about

national ADP of 755,896,15 there were 38 suicides per 100,000 inmates in detention facilities in

the problem of suicide among

2006, and that rate was approximately 3 times greater than the rate in the general population.

jail inmates is also reflected in
national correctional standards

This calculation is consistent with previously reported BJS data and it confirms that there has

that now require comprehensive

been a dramatic decrease in the suicide rate in detention facilities during the past 20 years. The

suicide-prevention programming,

nearly threefold decrease from 107 suicides in 1986 to 38 suicides in 2006 is extraordinary.

better training of jail staff, and

Absent indepth scientific inquiry, there may be several explanations for the reduced suicide rate.

more indepth inquiry of suicide

During the past several years, NCIA’s prior national studies of jail suicide have given a face to this

risk factors during the intake

long-standing and often ignored public health issue in the nation’s jails. Findings from the studies

process.

have been widely distributed throughout the country and were eventually incorporated into suicideprevention training curricula. The increased awareness about the problem of suicide among jail
inmates is also reflected in national correctional standards that now require comprehensive suicideprevention programming, better training of jail staff, and more indepth inquiry of suicide risk fac­
tors during the intake process. Finally, litigation involving jail suicide has persuaded (or forced)
counties and facility administrators to take corrective actions in reducing the opportunity for future
deaths. Therefore, the antiquated mindset that “inmate suicides cannot be prevented” should for­
ever be put to rest.

46

14

Rates of suicide in holding facilities were not computed due to the unreliability of average daily population data.

15

See Sabol, Minton, and Harrison 2007.

National Study of Jail Suicide: 20 Years Later

Chapter 5. Conclusion

T

he primary goal of this study was to provide updated data on the extent and distribution of
inmate suicides throughout the country, as well as to gather recent descriptive data on the
demographic characteristics of each victim, characteristics of the incident, and characteristics

of the holding or detention facility that sustained the suicide. To that end, project staff compiled sig­
nificant data on inmate suicides throughout the country, and it is hoped that these findings can be
used as a resource tool for practitioners in expanding their knowledge base and for facility admin­
istrators in creating and/or revising sound policies and training curricula on suicide prevention.
Although the vast majority of

Comprehensive Suicide-Prevention Programming

facilities that sustained a suicide

The findings indicate that, although the vast majority of facilities that sustained a suicide had a
written suicide-prevention policy, the comprehensiveness of the program was questionable. For
example, even though many respondents reported that their facilities maintained an intake screen­

had a written suicide-prevention
policy, the comprehensiveness of
the program was questionable.

ing process to identify the suicide risk of inmates entering the facility, the process for most facilities
did not include verification as to whether the arresting and/or transporting officer(s) believed that
the newly arrived inmate was at risk for suicide, nor whether the inmate was at risk for suicide
during prior confinement. In addition, although the majority of respondents reported that their
facilities provided suicide-prevention training to staff, most of the training was 2 hours or less in
duration. Most surveyed facilities had a suicide watch protocol, but few provided for constant
observation. Further, only one-third of respondents reported the availability of protrusion-free hous­
ing for suicidal inmates and most did not provide a mortality review following an inmate suicide.
Consistent with national correctional standards, as well as practices in facilities that have effec­
tively reduced the opportunity for inmate suicide, all holding and detention facilities (regardless of
size and type) must have a detailed, written, suicide-prevention policy that addresses each of the
critical components discussed in the following sections (Hayes 2005; Metzner and Hayes 2006;
National Commission on Correctional Health Care 2008).

Training
All correctional, medical, and mental health personnel, as well as any staff who have regular
contact with inmates, should receive 8 hours of initial suicide-prevention training and 2 hours of
refresher training each year. The initial training should include instruction regarding administra­
tor and staff attitudes about suicide and how negative attitudes impede suicide-prevention efforts,
why correctional facilities’ environments are conducive to suicidal behavior, potential predisposing
factors to suicide, high-risk suicide periods, warning signs and symptoms, how to identify suicidal
inmates despite a denial of risk, components of the facility’s suicide-prevention policy, and liability

Chapter 5. Conclusion

47

issues associated with inmate suicide. The 2-hour refresher training should review the topics dis­
cussed during the initial training and also describe any changes to the facility’s suicide prevention
plan. The annual training should also include a general discussion of any recent suicides and/or
suicide attempts in the facility.
In addition, all staff who are in contact with inmates should be trained in standard first aid and
cardiopulmonary resuscitation (CPR) procedures, and all staff should learn how to use the emergen­
cy equipment located in each housing unit. To ensure an efficient emergency response to suicide
attempts, mock drills should be incorporated into both the initial and refresher training for all staff.

Identification, Referral, and Evaluation
Intake screening and ongoing assessment of all inmates are critical to a correctional facility’s
Screening should not be a single

suicide-prevention efforts. Screening should not be a single event but a continuous process because

event but a continuous process

inmates can become suicidal at any point during their confinement, including during initial admis­

because inmates can become

sion into the facility, after adjudication when the inmate is returned to the facility from court, after

suicidal at any point during their

receiving bad news or after suffering any type of humiliation or rejection, during confinement in

confinement.

isolation or segregation, and following a prolonged stay in the facility.
Intake screening for suicide risk can be included on the medical screening form or it can be a
separate form. The screening process should include questions about past suicidal ideation and/
or attempts; current ideation, threat, or a plan to commit suicide; prior mental health treatment or
hospitalization; any recent significant loss (e.g., job, relationship, death of family member or close
friend); history of suicidal behavior by a family member or close friend; suicide risk during prior
confinement; and the arresting and/or transporting officer(s)’ belief that the inmate is currently at
risk. Specifically, the suicide screening process should determine the following:
•	 Was the inmate a medical, mental health, or suicide risk during any prior contact and/or
confinement in this facility?
•	 Does the arresting and/or transporting officer have any information (e.g., from observed behav­
ior, documentation from sending agency or facility, conversation with family member) that indi­
cates the inmate is currently a medical, mental health, or suicide risk?
•	 Has the inmate ever attempted suicide?
•	 Has the inmate ever considered suicide?
•	 Is the inmate being treated for mental health or emotional problems, or has the inmate been
treated in the past?
•	 Has the inmate recently experienced a significant loss (e.g., relationship, death of family
member or close friend, job)?
•	 Has a family member or close friend ever attempted or committed suicide?
•	 Does the inmate feel there is nothing to look forward to in the immediate future (i.e., is
the inmate expressing helplessness and/or hopelessness)?
•	 Is the inmate thinking of hurting and/or killing himself or herself?

48

National Study of Jail Suicide: 20 Years Later

An inmate’s verbal responses during the intake screening process are critically important when
assessing the risk of suicide. However, staff should not rely exclusively on an inmate’s statement
that he or she is not suicidal and/or does not have a history of mental illness or suicidal behavior,
particularly when the inmate’s behavior, actions, or previous confinement in the facility suggest
otherwise. The process should also include procedures for referring the inmate to mental health
and/or medical personnel for a more thorough and complete assessment.
In addition, given the strong association between suicide and placement in isolation or a special
housing unit (e.g., disciplinary and/or administrative segregation), any inmate assigned to such
a special housing unit should receive a written assessment for suicide risk by medical or mental
health staff upon admission to the placement.
Finally, findings from this study demonstrate that the majority of suicides do not occur within the
first 24 hours of confinement. In addition, various high-risk periods are associated with potentially
suicidal behavior, including whether the inmate has an upcoming date for a court hearing and fol­
lowing a telephone call or scheduled visit. Staff must be aware of these high-risk periods so they
can effectively assess inmates’ risk for suicide.

Various high-risk periods are

Communication

suicidal behavior, including

The screening and assessment process is one of several tools that can be used to identify suicide

whether the inmate has

associated with potentially

risk in inmates. This process, coupled with staff training, will be successful only if an effective meth­

an upcoming date for a

od of communication is in place at the facility.

court hearing and following

The inmate may exhibit certain behaviors that indicate a risk of suicide. If these behaviors are

uled visit.

a telephone call or sched­

detected and communicated to others, the likelihood of suicide can be reduced. In addition, most
suicides can be prevented by correctional staff who establish trust and rapport with inmates, gather
pertinent information, and take action. Three levels of communication are important in preventing
inmate suicides:
•	 Communication between the arresting and/or transporting officer and correc­
tional staff. In many ways, suicide prevention begins at the point of arrest. What an arrestee
says and how he or she behaves during arrest, transport to the facility, and at intake are crucial
in detecting suicidal behavior. The scene of arrest is often the most volatile and emotional time
for the individual, and the arresting officer should pay close attention to the arrestee during this
time. Suicidal behavior may occur because of the arrestee’s feelings of anxiety or hopelessness,
and previous suicidal behavior can be confirmed by family members and/or friends. The arrest­
ing or transporting officer must communicate any pertinent information about the arrestee’s well­
being to correctional staff. It is also critically important for correctional staff to maintain open
lines of communication with family members, who often have pertinent information about the
inmate’s mental health.
•	 Communication among facility staff (correctional, medical, and mental health
personnel). Effective management of suicidal inmates depends on communication between the
facility’s correctional personnel and other professional staff. Because inmates can become sui­
cidal at any point during confinement, correctional staff must maintain awareness, share infor­
mation, and make appropriate referrals to mental health and medical staff. At a minimum, the

Chapter 5. Conclusion

49

facility’s shift supervisor should ensure that appropriate correctional staff are properly informed
of the status of each inmate placed on suicide precautions. At the end of a shift, the shift super­
visor should inform the incoming shift supervisor about the status of all inmates on suicide pre­
cautions. Multidisciplinary team meetings that include correctional, medical, and mental health
personnel should occur on a regular basis to discuss the status of inmates on suicide precau­
tions. Finally, the authorization for suicide precautions, any changes in suicide precautions, and
observation of inmates placed on precautions should be documented on designated forms and
distributed to appropriate staff.
•	 Communication between facility staff and the suicidal inmate. Facility staff must use
various communication skills with the suicidal inmate, including active listening, staying with the
inmate if immediate danger is suspected, and maintaining contact through conversation, eye
Housing assignments should be
based on the ability to maximize
staff interaction with the inmate,
not on decisions that heighten
depersonalizing aspects of
confinement.

contact, and body language. Correctional staff should trust their own judgment and observa­
tion of risk behavior and should not let other facility personnel (including mental health staff)
convince them to ignore signs of suicidal behavior. Poor communication among correctional,
medical, and mental health personnel, as well as with outside entities (e.g., arresting or refer­
ral agencies and family members) is a common factor in many custodial suicides. A lack of
respect, personality conflicts, and boundary issues often lead to problems with communication.
Simply stated, facilities that maintain a multidisciplinary approach avoid preventable suicides.

Housing
When determining the most appropriate housing location for a suicidal inmate, correctional facility
officials (with concurrence from medical and/or mental health staff) often tend to physically isolate
(or segregate) and sometimes restrain the individual. Although these responses may be convenient
for facility staff, they are detrimental to the inmate because isolation escalates a sense of alien­
ation and further removes the individual from proper staff supervision. Whenever possible, suicidal
inmates should be housed in the general population unit, mental health unit, or medical infirmary,
and should be located close to facility staff. Further, removal of an inmate’s clothing (excluding
belts and shoelaces) and the use of physical restraints (e.g., restraint chairs or boards, leather
straps, handcuffs, and straitjackets) should be avoided whenever possible; these measures should
only be used as a last resort when the inmate is physically engaging in self-harming behavior.
Housing assignments should be based on the ability to maximize staff interaction with the inmate,
not on decisions that heighten depersonalizing aspects of confinement.
All cells designated to house suicidal inmates should be as suicide resistant as possible, free of all
obvious protrusions, and provide full visibility. These cells should contain tamperproof light fixtures
along with smoke detectors and ceiling and/or wall air vents that are free of protrusions. In addi­
tion, the cells should not contain any live electrical switches or outlets, bunks with open bottoms,
any type of clothing hook, towel racks on desks or sinks, radiator vents, or any other object that
provides an easy anchoring device for hanging. Each cell door should contain a heavy-gauge
Lexan (or equivalent grade) clear panel that is large enough to allow staff a full and unobstructed
view of the cell interior. Finally, each housing unit in the facility should have an emergency
response bag. The bag should contain emergency equipment, including a first aid kit, a pocket

50

National Study of Jail Suicide: 20 Years Later

mask or face shield, a self-inflating resuscitator bag, and a rescue tool (to quickly cut through
fibrous material). Correctional staff should ensure that such equipment is in working order on a
daily basis.

Observation and Treatment Plan
Two levels of observation are generally recommended for suicidal inmates:
•	 Close observation is recommended for the inmate who is not actively suicidal but expresses sui­
cidal ideation and/or has a recent history of self-harming behavior. In addition, an inmate who
denies suicidal ideation or does not threaten suicide, but demonstrates other behavior (through
actions, current circumstances, or recent history) that could indicate the potential for self-injury,
should be placed under close observation. Staff should observe such an inmate in a protrusionfree cell at staggered intervals not to exceed every 10 minutes (e.g., at 5 minutes, 10 minutes,
7 minutes).
•	 Constant observation is recommended for the inmate who is actively suicidal (i.e., either threat­
ening or engaging in suicidal behavior). Staff should observe such an inmate on a continuous,
uninterrupted basis. Some jurisdictions also use an intermediate level of supervision, with obser­
vation at staggered intervals that do not exceed 5 minutes.
Other aids (e.g., closed-circuit television monitors, inmate companions, and cellmates) can be used
as a supplement to, but never as a substitute for, these observation levels.
Mental health staff should assess and interact with (not just observe) the suicidal inmate daily. The
daily assessment should focus on the inmate’s current behavior as well as changes in thoughts and
behavior during the past 24 hours. For example, mental health staff can ask the following ques­
tions: “What are your current feelings and thoughts?”, “Have your feelings and thoughts changed
over the past 24 hours?”, and “What are some of the things you have done or can do to change
these thoughts and feelings?”
An individualized treatment plan (including followup services) should be developed for each
inmate on suicide precautions. Qualified mental health staff should develop the plan in conjunction
with both the inmate and medical and correctional personnel. The treatment plan should describe
signs, symptoms, and the circumstances under which the risk for suicide is likely to recur; how the
inmate can avoid having suicidal thoughts; and actions the inmate and staff will take if suicidal
ideation recurs.
Finally, because of the strong correlation between prior suicidal behavior and suicide, and to
safeguard the continuity of care for suicidal inmates, all inmates who are discharged from suicide
precautions should remain on mental health caseloads and receive regularly scheduled followup
assessments by mental health personnel until they are released from custody. Although there is no
nationally accepted schedule for followup, 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.

Chapter 5. Conclusion

51

Intervention
National correctional standards and practices generally acknowledge that a facility’s policy regard­
ing intervention should include three components. First, all staff who have contact with the inmate
should be trained in standard first aid procedures and CPR. Second, a staff member who discovers
an inmate engaging in self-harming behavior should immediately survey the scene to assess the
severity of the emergency, alert other staff to call for medical personnel if necessary, and begin
standard first aid and/or CPR if necessary. If facility policy prohibits an officer from entering a cell
without backup support, the first responding officer should, at a minimum, make the proper noti­
fication for backup support and medical personnel, secure the area outside the cell, and retrieve
the housing unit’s emergency response bag. Third, correctional staff should never presume that the
victim is dead, but rather should initiate and continue appropriate lifesaving measures until medical
personnel arrive. Finally, although not all suicide attempts require emergency medical intervention,
all such attempts do require immediate intervention and assessment by mental health staff.

Notification and Reporting
In the event of a serious suicide attempt (i.e., one that requires hospitalization for injuries) or a
completed suicide, all appropriate officials should be notified through the chain of command.
Following the incident, the victim’s family and appropriate outside authorities should be notified
immediately. All staff who had contact with the victim before the incident should be required to sub­
mit a statement that includes any information they may have about the inmate and/or the incident.

Critical Incident Stress Debriefing and Mortality-Morbidity Review
An inmate suicide is extremely stressful for both staff and other inmates. Staff members who recent­
ly had contact with the inmate may also feel ostracized by other personnel and administration offi­
cials. Following a suicide, a correctional officer may experience guilt because he or she might ask,
“What if I had made my cell check earlier?” Staff and inmates who are affected by a traumatic
event such as inmate suicide should be offered immediate assistance. One form of assistance is
critical incident stress debriefing (CISD). A CISD team, composed of professionals trained in crisis
intervention and traumatic stress awareness (e.g., police officers, paramedics, firefighters, clergy,
and mental health personnel), allows staff and inmates to process their feelings about the incident,
develop an understanding of critical stress symptoms, and seek ways of dealing with those symp­
toms. For maximum effectiveness, the CISD process or other appropriate support services should
occur within 24 to 72 hours of the critical incident.
Every completed suicide, as well as every serious suicide attempt, should be examined through a
mortality-morbidity review process. If resources permit, a clinical review through a psychological
autopsy is also recommended. Ideally, an outside agency should coordinate the mortality-morbidity
review to ensure impartiality. This review, which is separate and apart from other formal investiga­
tions that may be required to determine the cause of death, should include the following:
• A critical inquiry of the circumstances surrounding the incident.
• Facility procedures relevant to the incident.
• Relevant training that involved staff received.
• Pertinent medical and mental health services or reports involving the victim.

52

National Study of Jail Suicide: 20 Years Later

•	 Possible precipitating factors that led to the suicide or serious suicide attempt.
•	 Recommendations, if any, for changes in policy, training, physical plant, medical or mental
health services, and operational procedures.

Future Training Efforts
Although findings from this study show that most of the facilities that experienced a suicide provid­
ed some type of suicide-prevention training to staff, a sizable number (approximately 38 percent)
did not offer any training. In addition, almost two-thirds (63.3 percent) of the facilities that expe­
rienced a suicide either did not provide suicide-prevention training to staff or did not provide the
training on an annual basis. Only a handful of facilities provided a full day of suicide prevention
training to staff.
In addition, as indicated by the report’s findings, many of the demographic characteristics of sui­
cide victims and characteristics of the incidents have changed dramatically since prior studies. For
example, suicide victims previously confined on “minor other” offenses were more recently con­

Correctional administrators should

fined on “personal and/or violent” charges. Intoxication was previously viewed as a leading pre­

ensure that suicide-prevention

cipitant to inmate suicide, yet recent data indicate that this factor is now found in only a minority

training curricula are developed

of cases. Whereas more than half of all jail suicide victims were previously dead within the first 24

and/or revised to reflect these

hours of confinement, current data show that less than one-quarter of all victims commit suicide dur­

new research findings and that all

ing this time period, with an equal number of deaths occurring between 2 and 14 days of confine­

correctional, medical, and mental

ment. In addition, inmates who committed suicide were far less likely to be housed in isolation than

health personnel receive regular

previously reported, yet for unknown reasons they were less likely to be found within 15 minutes of

and comprehensive instruction in

the last observation by staff.

suicide-prevention methods.

For the reasons stated above, correctional administrators should ensure that suicide-prevention
training curricula are developed and/or revised to reflect these new research findings and that all
correctional, medical, and mental health personnel receive regular and comprehensive instruction
in suicide-prevention methods. At a minimum, initial suicide-prevention training should include but
not be limited to the following topics: administrator and staff attitudes about suicide and how nega­
tive attitudes impede suicide-prevention efforts, ways in which correctional facility environments are
conducive to suicidal behavior, potential predisposing factors to suicide, high-risk suicide periods,
warning signs and symptoms, how to identify suicidal inmates even if they deny they are at risk,
components of the facility’s suicide-prevention policy, and liability issues associated with inmate
suicide. Annual refresher training should include a review of administrator and staff attitudes
about suicide and how negative attitudes impede suicide-prevention efforts, predisposing risk fac­
tors, warning signs and symptoms, how to identify suicidal inmates despite a denial of risk, and
a review of any changes to the facility’s suicide-prevention plan. The annual training should also
include a general discussion of any recent suicides and/or suicide attempts in the facility.
Holding or detention facility staff will lack the means to both identify and manage suicidal inmates
if they have received little or no training in suicide-prevention methods. Lives will continue to be
lost and jurisdictions will incur unnecessary liability from these tragic deaths if administrators do
not create and maintain effective training programs.

Chapter 5. Conclusion

53

Data Limitations and Further Research Needed
Project staff mailed survey requests to nearly 16,000 jail facilities in the United States as well
as to hundreds of secondary sources (e.g., state medical examiner offices, state and federal jail
inspection and/or regulatory agencies, state police and/or bureau of investigation offices, and
private health-care providers that have contracts with county and municipal jurisdictions). This mail­
ing, along with a review of newspaper articles retrieved from Internet search engines, yielded an
accounting of jail suicides during 2005 and 2006 that is as accurate as is reasonably possible.
However, because of underreporting and a reluctance to share data, it is not certain whether every
death was identified. In addition, a sizable number of survey respondents were unable to supply
some data and answered “unknown” to several key variables (e.g., substance abuse, medical and
mental health, psychotropic medication, and history of suicidal behavior), thus reflecting either
inadequate intake screening, inadequate recordkeeping, or a combination of both. Only about
one-third of respondents conducted mortality reviews following the suicides; this factor also hin­
dered data collection efforts.
In addition, although this study represented the National Institute of Corrections’ third comprehen­
sive national survey of inmate suicide, the current findings invite additional research. For example,
future research could explore in more detail the reason(s) behind the occurrence of more suicides
during the first 2 to 14 days of confinement rather than within the first 24 hours of confinement.
This study revealed a possible relationship between suicide and an inmate’s confinement for sexual
assault and/or murder of a child (which accounted for approximately 7 percent of all suicides), but
additional research is necessary to explain the reasons for this relationship. Further research is also
necessary to explore the relationship between the occurrence of inmate suicides and recent court
hearings, telephone calls, and visitation, as well as other possible precipitating factors that study
respondents could not identify. The identification of precipitating factors to inmate suicide is criti­
cally important to the field’s further understanding of the problem.

The Continuing Challenge of Prevention
In conclusion, findings from this study create a formidable challenge for both correctional and
health-care officials as well as their respective staffs. Although the knowledge base continues to
increase, which seemingly corresponds to a dramatic reduction in the rate of inmate suicide in
detention facilities, much work lies ahead. The data indicate that inmate suicide no longer occurs
mostly during the first 24 hours of confinement and can occur at any time during an inmate’s con­
finement. Given that roughly the same number of deaths occurred within the first few hours of cus­
tody as occurred in more than several months of confinement, information gathered about current
suicide risk during intake screening should be viewed as time limited. Because inmates can be at
risk at any point during confinement, the greatest challenge for those who work in the correctional
system is to view the issue as one that requires a continuum of comprehensive suicide-prevention
services aimed at the collaborative identification, continued assessment, and safe management of
inmates at risk for self-harm.

54

National Study of Jail Suicide: 20 Years Later

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Clark, D., and S. Horton-Deutsch. 1992.

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Cohen, F. 2008. The Mentally Disordered Inmate
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Cox, J., and P. Morschauser. 1997. “A Solution

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to the Problem of Jail Suicide.” Crisis: The Journal

Atlas, R. 1989. “Reducing the Opportunity for
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Aufderheide, D. 2000. “Conducting the
Psychological Autopsy in Correctional Settings.”
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Bonner, R. 1992. “Isolation, Seclusion, and
Psychological Vulnerability as Risk Factors for
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18:178–84.
Daniel, A., and J. Fleming. 2006. “Suicides in
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Davis, M., and J. Muscat. 1993. “An Epidemio­
logic Study of Alcohol and Suicide Risk in Ohio
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Prediction of Suicide. New York: Guilford Press,

DuRand, C., G. Burtka, E. Federman, J. Haycox,

pp. 398–419.

and J. Smith. 1995. “A Quarter Century of

Bonner, R. 2000. “Correctional Suicide
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370–76.

Suicide in a Major Urban Jail: Implications for
Community Psychiatry.” American Journal of
Psychiatry 152:1077–80.
Farmer, K., A. Felthous, and C. Holzer. 1996.
“Medically Serious Suicide Attempts in a Jail
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Felthous, A. 1994. “Preventing Jailhouse

(eds.), Handbook of Correctional Mental

Suicides.” Bulletin of the American Academy of

Health. Washington, DC: American Psychiatric

Psychiatry and the Law 22:477–88.

Publishing, pp. 69–88.

Frottier, P., S. Fruehwald, K. Ritter, R. Eher, J.

Hayes, L. 2006. “Suicide Prevention and

Schwaerzler, and P. Bauer. 2002. “Jailhouse

Designing Safer Prison Cells.” In G. Dear (ed.),

Blues Revisited.” Social Psychiatry and Psychiatric

Preventing Suicide and Other Self-Harm in Prison.

Epidemiology 37:68–73.

New York: Palgrave MacMillan, pp. 167–74.

Fruehwald, S., P. Frottier, T. Matschnig, F. Koenig,

Hayes, L. 2007. “Reducing Inmate Suicides

S. Lehr, and R. Eher. 2004. “Do Monthly or

Through the Mortality Review Process.” In R.

Seasonal Variations Exist in Suicides in a High-

Greifinger (ed.), Public Health Behind Bars: From

Risk Setting?” Psychiatry Research 121:263–69.

Prisons to Communities. New York: Springer,

Goss, J., K. Peterson, L. Smith, K. Kalb, and
B. Brodey. 2002. “Characteristics of Suicide

Hayes, L. 2009. “Juvenile Suicide in Confine­

Attempts in a Large Urban Jail System With

ment: A National Survey.” Suicide and Life-

an Established Suicide Prevention Program.”

Threatening Behavior 39:353–63.

Psychiatric Services 53:574–79.

He, X., A. Felthous, C. Holzer, P. Nathan, and

Hayes, L. 1983. “And Darkness Closes In: A

S. Veasey. 2001. “Factors in Prison Suicide: One

National Study of Jail Suicides.” Criminal Justice

Year Study in Texas.” Journal of Forensic Sciences

and Behavior 10:461–84.

46(4):896–901.

Hayes, L. 1989. “National Study of Jail Suicides:

Heron, M., D. Hoyert, S. Murphy, J. Xu, K.

Seven Years Later.” Psychiatric Quarterly

Kochanek, and B. Tejada-Vera. 2009. “Deaths:

60:7–29.

Final Data for 2006.” National Vital Statistics

Hayes, L. 1995. “Prison Suicide: An Overview
and Guide to Prevention.” The Prison Journal
75:431–56.
Hayes, L. 1996. “Jail Standards and Suicide
Prevention: Another Look.” Jail Suicide/Mental
Health Update 6:9–11.
Hayes, L. 1998. “Model Suicide Prevention
Programs, Part III.” Jail Suicide/Mental Health
Update 8:1–7.
Hayes, L. 2003. “A Jail Cell, Two Deaths, and
a Telephone Cord.” Jail Suicide/Mental Health
Update 11:1–8.
Hayes, L. 2005. “Suicide Prevention in Cor­
rectional Facilities.” In C. Scott and J. Gerbasi

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Reports 57(14). Hyattsville, MD: U.S. Department
of Health and Human Services, Centers for
Disease Control and Prevention, National Center
for Health Statistics.
Hughes, D. 1995. “Can the Clinician Predict
Suicide?” Psychiatric Services 46:449–51.
James, D., and L. Glaze. 2006. Mental Health
Problems of Prison and Jail Inmates. Special
Report. Washington, DC: U.S. Department of
Justice, Office of Justice Programs, Bureau of
Justice Statistics.
Karberg, J., and D. James. 2005. Substance
Dependence, Abuse, and Treatment of Jail
Inmates, 2002. Special Report. Washington,
DC: U.S. Department of Justice, Office of Justice
Programs, Bureau of Justice Statistics.

Kovasznay, B., R. Miraglia, R. Beer, and B. Way.

Mumola, C. 2005. Suicide and Homicide in

2004. “Reducing Suicides in New York State

State Prisons and Local Jails. Special Report.

Correctional Facilities.” Psychiatric Quarterly

Washington, DC: U.S. Department of Justice,

75:61–70.

Office of Justice Programs, Bureau of Justice

Lester, D., and B. Yang. 2008. “Calculating Jail

Statistics.

Suicide Rates: A Rebuttal to Michael O’Toole.”

Mumola, C., and M. Noonan. 2008. Deaths in

American Jails January/February:45–46.

Custody Statistical Tables. Washington, DC: U.S.

Marcus, P., and P. Alcabes. 1993. “Character­
istics of Suicides by Inmates in an Urban Jail.”
Hospital and Community Psychiatry 44:256–61.
Maris, R. 1992. “Overview of the Study of
Suicide Assessment and Prediction.” In R. Maris,
A. Berman, J. Maltsberger, and R. Yufit (eds.),

Department of Justice, Office of Justice Programs,
Bureau of Justice Statistics.
National Commission on Correctional Health
Care. 2008. Standards for Health Services in
Jails, 8th Edition. Chicago: National Commission
on Correctional Health Care.

Assessment and Prediction of Suicide. New York:

New York State Department of Correctional

Guilford Press, pp. 3–22.

Services. 2002. Inmate Suicide Report,

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1995–2001. Albany, NY: New York State
Department of Correctional Services.

Department of Justice, Office of Justice Programs,

O’Toole, M. 2008. “Response to David Lester

Bureau of Justice Statistics.

and Bijon Yang.” American Jails January/

Metzner, J. 2002. “Class Action Litigation in

February:48–51.

Correctional Psychiatry.” Journal of the American

Patterson, R., and K. Hughes. 2008. “Review of

Academy of Psychiatry and the Law 30:19–29.

Completed Suicides in the California Department

Metzner, J., and L. Hayes. 2006. “Suicide
Prevention in Jails and Prisons.” In R. Simon and

of Corrections and Rehabilitation, 1999 to
2004.” Psychiatric Services 59:676–82.

R. Hales (eds.), Textbook of Suicide Assessment

Quinton, R., and D. Dolinak. 2003. “Suicidal

and Management. Washington, DC: American

Hangings in Jail Using Telephone Cords.” Journal

Psychiatric Publishing, pp. 139–55.

of Forensic Sciences 48:1151–52.

Minton, T., and W. Sabol. 2009. Jail Inmates

Sabol, W., T. Minton, and P. Harrison. 2007.

at Midyear 2008 – Statistical Tables. Special

Prison and Jail Inmates at Midyear 2006. Special

Report. Washington, DC: U.S. Department of

Report. Washington, DC: U.S. Department of

Justice, Office of Justice Programs, Bureau of

Justice, Office of Justice Programs, Bureau of

Justice Statistics.

Justice Statistics.

Moscicki, E. 2001. “Epidemiology of Completed

Salive, M., G. Smith, and T. Brewer. 1989.

and Attempted Suicide: Toward a Framework

“Suicide Mortality in the Maryland State Prison

for Prevention.” Clinical Neuroscience Research

System, 1979 Through 1987.” Journal of the

1:310–23.

American Medical Association 262:365–69.

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Sanchez, H. 2006. “Inmate Suicide and the

White, T., and D. Schimmel. 1995. “Suicide

Psychological Autopsy Process. Jail Suicide/

Prevention in Federal Prisons: A Successful

Mental Health Update 15:5–11.

Five-Step Program.” In L. Hayes (ed.), Prison

Sanville v. Scaburdine, U.S. District Court,
Eastern District of Wisconsin, Case No.
99–C–715 (2002).
Stone, W. 1987. “Jail Suicide.” Corrections
Today December:84–87.
Thienhaus, O., and M. Piasecki. 1997.
“Assessment of Suicide Risk.” Psychiatric
Services 48:293–94.
Tittle v. Jefferson County Commission, 966
F.2d 606 (11th Cir. 1992).
Way, B., D. Sawyer, S. Barboza, and R. Nash.
2007. “Inmate Suicide and Time Spent in Special
Disciplinary Housing in New York State Prison.”
Psychiatric Services 58:558–60.

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Suicide: An Overview and Guide to Prevention.
Washington, DC: U.S. Department of Justice,
National Institute of Corrections, pp. 46–57.
Winkler, G. 1992. “Assessing and Responding to
Suicidal Jail Inmates.” Community Mental Health
Journal 28:317–26.
Winter, M. 2003. “County Jail Suicides in a
Midwestern State: Moving Beyond the Use of
Profiles.” The Prison Journal 83:130–48.
Woodward v. Myres, U.S. District Court,
Northern District of Illinois, Case No.
00–C–6010 (2003).

Appendix A


NATIONAL STUDY OF JAIL SUICIDES
INFORMATION REQUESTED BY:
THE NATIONAL CENTER ON
INSTITUTIONS AND ALTERNATIVES
ON BEHALF OF THE
NATIONAL INSTITUTE OF CORRECTIONS
U.S. DEPARTMENT OF JUSTICE

Dear Sheriff, Police Chief, and/or Facility Commander:
The National Institute of Corrections, U.S. Department of Justice, has requested the National Center on
Institutions and Alternatives (NCTA) to conduct a national study on jail suicides. You may recall that a
similar comprehensive study was conducted by NCTA during the 19805. With your assistance, the project
will utilize collected on inmate suicides to generate programmatic recommendations to confront this
issue. This infonnation can then be employed by your agency and others in an effort to reduce the
occurrence of future inmate suicides.

DATA PROVIDED BY INDIVIDUAL FACILITIES WILL BE CODED AND HELD IN THE
STRICTEST CONFIDENCE. RESULTS OF THIS STUDY WILL BE PRESENTED IN SUMMARY
FASHION, THUS PREVENTING THE DIRECT LINKAGE OF SPECIFIC DATA TO THE
PARTICULAR FACILITY FROM WHICH THE INFORMATION ORIGINATED.
Data requested for this studv (see over) should be limited to inmate suicides occurring between the
two-year period of Januarv 1,2005 thru December 31, 2006.
In order to facilitate data compilation, we ask that you utilize the definitions provided on the back of this

fonn. When this is not possible, please infonn us of specific differences in your reporting.
For your convenience in submitting the completed form, we have enclosed a self-addressed, business
reply envelope. We ask that the completed form be returned within thirty (30) days of its receipt. We also
ask that you return the completed form only if you had a suicide(s) during 2005 and/or 2006.
If you have any questions regarding completion of this form or the study, please feel free to contact Mr.
Lindsay M. Hayes of NCIA at (508) 337·8806 or lhayesta@msn.com. Thank you for your cooperation.
Copies of the final report will be available upon request.
Sincerely,

Morris L. Thigpen, Director
National Institute of Corrections
U.S. Justice Department

Lindsay M. Hayes, Project Director
National Center on Institutions
and Alternatives

Appendix A

59

DEFINITIONS
SUICIDE: Any death of an
3n individual while in custody of any law enforcement agency resulting from or leading
\vhich the individual was
directly from any self-inflicted act perpetrated by that individual. Further, any incident in which
left in a comatose and/or
andlor brain-dead state would be included within this definition. (NOTE: For purposes
pumoses of this
study, an individual who attempted suicide within the facility yet later died enroute to or at the hospital or other
study
health care provider is classified as an inmate suicide and should be reported bcJO\v.)
below.)

JAIL:
multiJAIL: Any facility operated by a local jurisdiction (e.g., county, municipality, etc.), private entity, or multi­
jurisdictional authority whose purpose is the confinement of individuals primarily apprehended by law enforcement
personnel. Jails, as defined here, would include temporary holding and pre-trial detention facilities, lockup facilities
which normally detain persons for less than 72 hours, as well as facilities which
\-vhich normally detain individuals or have
committed/sentenced offenders for more than 72 hours. The definition includes facilities which are housing inmates
for another jurisdiction (e.g., state or federal prison system), including privately operated jails and regional jails.

QUESTIONS
In the spaces provided below, please indicate the TOTAL NUMBER OF INMATE SUICIDES occurring in yuur
your
facility during the two-year period between
31,, 2006
2006.. Please only
bctwecn JANUARY I, 2005 THRU DECEMBER 31
complete the fonn if your jail facility had a suicidc(s) during this two-year
h,.,o-year period. If you have any questions
feel free to contact
cuntaet Mr. Lindsay M. Hayes of NCIA at (508)
regarding completion of this form or the study, please fed
33 7-8806 or Ihayesta@msn.com.
Ihayesla@msn.com.
337-8806
1.
I.

inmatc suicides between:
bctween:
N umber of inmate

January 1,2005 and December
Dccember 31,2005 _ _ _ _ __

January 1,2005
I, 2005 and December 31,2006
31, 2006 _ _ _ _ __
2.

Which of the following categories best describes your facility? (Please only check one category.)
a)

Facility for committed/sentenced offenders

b)

Detention Facility (0 to
Temporary Holding or Pre-Trial Detentioo
10 72 hours)

c)

Pre-Trial Detention Facility (over 72 hours)

d)

Other (Specify: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _- i

THE FOLLOWING WILL BE UTILIZED FOR INTERNAL PURPOSES ONLY
Completed by (name/title):
Name of Facility:

Street Address:

City, State, Zip:
Telephone/E-Mail:

(

__
__
___
_ _ E-Mail:__ _ _ _ _ _ _ _ __
) ___

Please return the completed survey within 30 days of receipt to:
NCIA
P,O, BOX 111
MANSFIELD, MA 02048

60

National Study of Jail Suicide: 20 Years Later

Appendix B


PHASE 2: NATIONAL STUDY OF JAIL SUICIDES
NATIONAL CENTER ON INSTITUTIONS AND ALTERNATIVES
Acting as Collecting Agent for the
NATIONAL INSTITUTE OF CORRECTIONS
U.S. DEPARTMENT OF mSTICE
Items contained in this questionnaire refer to a suicide that occurred in your facility between January 1, 2005 and
December 31, 2006 as identified during Phase 1 of the National Study of Jail Suicides project. Please complete the
following questionnaire by checking the appropriate boxes andlor filling in the blanks (and use additional sheets if
necessary). Definitions for certain terms used in this questionnaire appear on page 8.
DATA PROVIDED WILL BE CODED AND HELD IN THE STRICTEST CONFIDENCE. RESULTS OF THIS
STUDY WILL BE PRESENTED IN SUMMARY FASHION, THEREFORE, VICTIM AND FACILITY NAMES
WILL NOT APPEAR IN ANY PROJECT REPORT.
We ask that you complete and return this questionnaire within 30 days. Should you have any questions or concerns
regarding completion of this questionnaire, please contact Lindsay M. Hayes, Project Director, National Center on
Institutions and Alternatives (NCIA) , P.O. Box Ill , Mansfield, Massachusetts 02048, 508/337-8806, e-mail:
LHayesta@msn.com.
NAMEOFFACTUTY_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ STATE. _ _ __
PART A: PERSONAL CHARACTERISTICS OF VICTIM
\)

Victim's Name (or any other identifiable notation): - - - c - - - - c - - - - - - - ; o c - : - - - - - : - ; - ; - Last
First
M.l.

2)

RaceJEthnicity:

(I )_ _ Caucasian

(4) _ _American Indian

(2)_ _ African-American
(3l_ _Hispanic

(8) _ _Other (Specify_ _ _ __
(9l _ _Unknown
(2) _ _Female

3)

Sex:

(I)_ _Male

4)

Date-of -Birth:

_

5)

Ma rital Status:

(ll_ _ Sing1e
(2l_ _Married
(3)_ _ Separated
(4l_ _Divorced

1_

1-

or

Years-Old

(5l _ _Widowcd
(6) _ _Common-Law Relationship

(8) _ _Othcr (Spccify
(9l _ _Unknown

)

Please specify Current Charge(s) for which the victim was confined at time of suicide and whether victim was being
Detained or had been Sentenced on those charge(s).
CHARGE(S)

7a)

Did the victim have a record of Prior Arrests?
(1)_ _Yes
(2)_ _No

DETAINED
(1)_ _
(2)_ _
(3)_ _

SENTENCED
(1) _ _
(2) _ _
(3) _ _

(9) _ _ Unknown

Appendix B

61

7b)

Tfthe victim had a prior arrest record, specify the Most Recent Prior Charges.
Most Recent Prior Chargers)

8)

What was the total Length of Confinement that the victim had been in your facility prior to their death? (Tfless
than two days, indicate in hours.)
Hours

9a)

_ _ Days

Months

Years

Did the victim have a history of Substance Abuse?
(J)_ _Yes

(2l_ _No

(9l_ _Unknown

9b)

If the victim had a history of substance abuse, briefly Describe Type of Substance Abuse. _ _ _ __

lOa)

Did the victim have a history of Medical Problems?
(Jl_ _Yes

(2)_ _No

(9l_ _Unknown

lOb)

If the victim had a history of medical problems, briefly Describe Type of Medical Problems. _ _ __

lla)

Did the victim have a history of Mental Illness?
(I)_ _ Yes

(2)_ _No

(9)_ _ Unknown

11 b)

Tfthe victim had a history or mental illness, briefly Describe Type of MentaITllness. _ _ _ _ _ __

12a)

Did the victim have a history of taking Psychotropic Medication?
(Jl_ _Yes

(2)_ _No

(9l_ _Unknown

12h)

Tfthe victim had a history of taking psychotropic medication, briefly Describe Type of Psychotropic
Medication(s) . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

12c)

Was the victim receiving Psychotropic Medication during the most recent confinement?
(Jl_ _Yes

12d)

62

Date

(2l_ _No

(9l_ _ Unknown

If the victim was receiving psychotropic medication during the most recent confinement, briefly Describe Type
of Psychotropic Medication. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

National Study of Jail Suicide: 20 Years Later

13a)

Did the victim have a history of Suicidal Behavior?
(ll _ _ Yes

(2l_ _ No

(9l_ _ Unknown

l3b)

lfthe victim had a history of suicidal behavior, briefly Describe Suicidal Behavior.,_ _ _ _ _ _ __

14a)

Was the victim ever on Suicide Watch (see definition on page 8) in your facility either during this
confinement or a prior confinement?
(2)_ _ No

(ll _ _ Yes

(9)_ _ Unknown

14b)

If the victim had previously been on Suicide Watch at any time in your facility, what was the Time Span
between Discharge from Suicide Watch and the Suicide, and Briefly Describe the Circumstances that
resulted in Discharge from Suicide Watch. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

15a)

Did the victim have a history of placement in Isolation or Segregation while in your facility?
(ll _ _ Yes

15b)

(2l_ _No

(9l_ _Unknown

If the victim had a history of placement in isolation or segregation, briefly Describe Type and Circumstances
of Isolation or Segregation._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

PART B: SmCIDE INCIDENT CHARACTERISTICS
16)

What was the Date and Time of the victim's suicide?
Oate: _ _I_ _ /200 _

17)

Time (found): _ _ _ _ ,am

_ _ _-'pm

What was the Method of suicide and the Instrument used?
Method

Instrument

(ll _ _ Hanging [trom
(bed, vent, etc,l] (01 l_ _ Clothing (specify type:_-=--:-o-__
(2l _ _ 0verdose
(02l_ _ Belt
(08) _ _Knife
(03l_ _ Shoelaoe
(3l _ _ Cutting
(09l _ _Glass
(4l _ _ Shooting
(04l_ _ Bedding
(lOl_ _ Drugs
(5l _ _ Jumping
(05)_ _ Telephone Cord
Specify_ _ __
(6l _ _ 1ngestion ofForeign Object(s)
(06l_ _ Razor
(8l _ _ 0ther
(07l_ _ 0ther (Specify_ _ _~
18)

What was the Time Span between the suicide and finding the victim?
(I l __ Less Than 15 Minutes
(2l _ _ Between 15 and 30 Minutes
(3l _ _ Between 30 and 60 Minutes

(4l_ _ Between 1 and 3 Hours
(5)_ _ Greater Than 3 Hours
(9l_ _ Unknown

Appendix B

63

19a)

At the time of the suicide, was the victim Under the Influence of:

(ll_ _Drugs

(4l_ _Neither Drugs or Alcohol
(9l_ _ Unknown

(2l_ _Alcohol
(3l_ _Drugs and Alcoho l
19b)

Tfthe victim was under the influence of drugs at the tim e of the suicide, briefly Describe the Type(s) of
Drugs:, _____________________________________________________________________

20a)

At the time of the suicide, was the victim assigned to a Single or Multiple Occupancy cell?
(2l ___ Multipl e

( l l ____ Sing lc

20b)

Tfthe victim was assigned a multipl e occupancy cell, Were other Inmates in the Cell at the Time ofthe
Suicide?
( l l ____Yes

2 1a)

22)

(2l ____No

(9l___ Unknown

Did either correctional or medical staff utilize an Automated External Defibrillator on the victim?
(2l____No

(9l___ Unknown

Was the victim under an y type ofIsolation or Segregation at the Time of the Suicide?
( l l_ _Yes

(2l_ _No

(9l_ _ Unknown

23b)

If the victim was under Isolation or Segregation at the time of the suicide, what was Time Span between
placement in Isolation/Segregation and the Suicide, and Briefly Describe Type and Circumstances of
Isolation or Segregation.___________________________________________________________

24a)

Was the victim under Suicide Watch (see definitions on page 8) at the Time of the Suicide?
( l l_ _Yes

24b)

(2l _ _No

(9l_ _ Unknown

If the v ictim was under suicide watch at the time of the suicide, what was the Frequency of Direct Visual
Observation by Staff (excluding any closed circuit television monitoring and/or inmate companion! inmate
observation aide)?

(l l___ Continuous
(2l_ _ Every 5 Minutes
(3 l__ Every 10 Minutes

64

(9)___Unknown

If Cardiopulmonary Resuscitation was not provided on the victim prior to the arrival of medical personnel,
briefl y Describe Reasons why it was not provided. ________________________________________

(l l_ _ Yes
23a)

(2l____No

Did correctional staff initiate Cardiopulmonary Resuscitation on the victim prior to the arrival of medical
personnel?

(l l____ Yes
2 1b)

(9l___Unknown

(5 l ___Every 30 Minutes
(6l _ _Evcry 60 Minutes
(8l_ _ 0ther (Specify_ _ _ _ _ _-'

National Study of Jail Suicide: 20 Years Later

(4l_ _ Evcry 15 Minutes

24c)

If the victim was under suicide watch at the time of the suicide, was Closed Circuit Television Monitoring
utilized as a method of observation?
(l)_ _ Yes

24d)

(2l _ _ No

(9l_ _ Unknown

Did facility staff utilize a No-Harm or No-Suicide Contract (see definition on page 8) at any time
with the victim?
(1)_ _ Yes

26a)

(9)_ _ Unknown

If the victim was under suicide watch at the time of the suicide, was an Inmate Companion/Inmate
Observation Aide (see definition on page 8) utilized as a method of observation?

(ll_ _ Yes
25)

(2) _ _No

(2l _ _No

(9l_ _ Unknown

Did the victim attend a Court Hearing or other Legal Proceeding in close proximity to the suicide?
(1)_ _ Yes

(2l _ _ No

(9)_ _ Unknown

26b)

If the victim attended a court hearing or other legal proceeding in close proximity to the suicide, what was Time
Span between the Hearing/Legal Proceeding and the Suicide, and Brietly Descrihe the Circumstances of
the Court Hearing/Legal Proceeding? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

27a)

Did the victim have a Visit or Telephone Call in close proximity to the suicide?
(I)_ _ Yes

(2l _ _No

(9)_ _ Unknown

27b)

Tfthe victim had a visit or telephone call in close proximity to the suicide, what was Time Span hetween the
Visit/Telephone Call and the Suicide, and Briefly Describe the Circumstances of the Visit/ Telephone
Call? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

28a)

Was the victim ever Assessed hy a Qualified Mental Health Professional (see definitions on page 8) prior to the
suicide?
(ll_ _ Yes

28b)

(9l_ _ Unknown

If the victim was assessed, specify the Last Contact by a Qualified Mental Health Professional prior to the
suicide? (lfless than two days, indicate in hours.)
_ _ Hours

29a)

(2l _ _No

_ _ Days

_ _ Weeks

_ _ Months

Was a Mortality Review (see definitions on page 8) conducted following the suicide?
(ll_ _ Yes

(2l _ _No

(9l_ _ Unknown

Appendix B

65

29b)

If a mortality review was conducted, did the process offer any Possible Precipitating Factors (i. e.,
circumstances which may have caused the victim to commit suicide) ? Tf yes, briefly li st: _ _ _ _ __

29c)

If a mortality review was conducted, did the process offer any Recommendations to Prevent F'uture Suicides?
If yes, briefly list: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

PART C: FACILITY CHARACTERISTICS
30)

The Facility is best described as a:
(I )_ _ facility for Pre- Trial Detainees and Sentenced Inmates
(2)_ _ Temporary Holding or Pre-Trial Detention facility (0 to 72 hours)
(3 )_ _ Pre-Trial Detention Facility (over 72 hours)
(4)_ _ Other (Specify: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

3 1)

At the time of the sui cide. what was the rated Capacity and Population o f the fa cility?
(I l __ Capacity

32)

The facility is Administered by a:
(l) _ _ State
(2)_ _ County

33)

(2 l _ _ No

(2l _ _ No

At the time ofthe suicide, did the Intake Screening pro cess include the ability to verify whether the
Arresting/Transporting Officer Believed the Victim was at Risk for Suicide?
(l l _ _ Yes

66

(2l _ _No

At the time ofthe sui cid e, did the Intake Screening pro cess includ e the ability to verify whether the victim had
been on Suicide Watch During a Prior Confinement?

(ll_ _ Ves
34c)

(8)_ _ Other (SpecilY_ _ _ __

At the time of the suicide, did the facility have an Intake Screening process to Identify Suicide Risk?
(Jl _ _ Yes

34b)

(3 )_ _ Municipality
(4) _ _ Pri vate Organization

At the time of the suicide, did the facility have a Written Suicide Prevention Policy?
(Jl _ _ Yes

34a)

(2 l_ _ Population

(2l _ _No

National Study of Jail Suicide: 20 Years Later

35a)

At the time of the suicide, had most (90% or more) correctional staff rece ived Suicide Prevention Tntining?
(1)_ _ Yes

35b)

(2) _ _No

If most correctional staff had received suicide prevention training, what was the Frequency and Duration of the
Suicide Prevention Training at the time of the suicide?
Frequency

Duration

(1) _ _Yearly
(8) _ _ Other (Specify_ _~

36)

At the time of the suicide, had most (90% or more) correctional statfreceived Certification in
Cardiopulmonary Resuscitation?
(1}_ _ Yes

37a)

(5) _ _ Every 30 Minutes
(6) _ _ Every 60 Minutes
(8) _ _ Other (Specify_ _ _ _ _ _~

At the time of the suicide, which of the following Best Describes Which Staff \\'ere Permitted to Downgrade
and Discharge an Inmate from Suicide \Vatch?
(l )_ _ Correctional
(2)_ _ Medical

38)

(2)_ _ No

If the facility had a suicide watch process at the time of the suicide, what was the Frequency Level(s) of Direct
Visual Observation by Staff? (Check all that apply.)
(I )_ _ Continuous
(2)_ _ Every 5 Minutes
(3 )_ _ Every 10 Minutes
(4}_ _ Every 15 Minutes

37c)

(2} _ _ No

At the time of the suicide, did the facility have a Suicide Watch process (excluding any closed circuit television
monitoring and/or inmate companion/inmate observation aide)?
(J)_ _ Yes

37b)

(OI) _ _Hours (Specify Number)
(02) _ _Minutes (Specify Number)

(3) _ _ Mental Health
(5) _ _A11 of the above
(4}_ _ Medical andlor Mental Health (8} _ _ Other (Specify->

At the time of the suicide, did the facility have a Housing process by which a suicidal inmate would be assign ed
to a safe, suicide-resistant, and protrusion-free cell?
(l)_ _ Yes

(2}_ _ No
DEFINITIONS

SUJCIDE WATCH : The Icvc1(s) of direct visual observation by staff that is given to an inmate identified as being at risk of sui cide.
closed circuit television, inmate companion/inmate observation aide, or any other non-staffmonitoring.

Exclude~

INMATE COMPANION/INMATE OBSERVATION AIDE: A designation by which another inmate is entrusted "lith the
responsibility of providing observation to an in mate on suicide watch.
NO-HARM/NO-SUICIDE CONTRACT: A verbal and/or written agreement between the inmate and facility staff/clinician in which
the irunate provides assurance they will not conunit suicide or engage in self-injurious behavior.

Appendix B

67

OUALrFrED MENTAL HEALTH PROFESS rONAL: An individual by virtue of their education, crcdcntials, and cxpericncc that
is permitted by law to evaluate and care for the mental health needs of patients. May include, but is not limited to, a psychiatrist,
psychologist, clinical social worker, and psychiatric nurSe.
MORTALITY REVIEW: An interdisciplinary committee process comprised of correctional, medical, and mental health personnel
that examines the evenl<; surrounding the death to determine if the incident was preventable. The review process may include
recommendations aimed at reducing the opportunity of future deaths.

THE FOLLOWING WILL BE USED FOR INTERNAL PURPOSES ONL Y:
Completed by (name/title): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Facility/Agency: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Address (streel):=_ _ _ _ _ _ _ _ _ _ _ _----;:-_ _ _ _ _ _ _ _ _ _ _---=:-::--:-_ _ __
City: _ _ _ _ _ _ _ _ _ _ _ _ ,State: _ _ _ _ _ _ _ _ _ _ _ Zip Code: _ _ __
Telephone:

E-~aiIAdd
~ress: -----------------------------------

Date Comp1etcd: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Would you like to be placed on the mailing list to receive the Jail SuicidelMental Health Update (a free quarlerly
newsletter devoted to jail suicide prevention and produced by the National Center on Institutions and Alternatives under
contract with the National Institute of Corrections, U.S. Justice Department) and receive notification of the findings from
this National Study of Jail Suicides?
Yes
_ _No

THANK YOU FOR YOUR COOPERA nON
Please return this completed questionnaire in the enclosed business reply envelope within 30 days to:

NCTA
P.O. Box III
Mansfield, MA 02048
or fax to NCIA at:

508/337-3083
or e-mall to:
Lhayesta@msn.com

68

National Study of Jail Suicide: 20 Years Later

U.S. Department of Justice
National Institute of Corrections
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