Chapter 16
Reducing Inmate Suicides Through
the Mortality Review Process
Lindsay M. Hayes

Suicide continues to be a leading cause of death in jails across the country,
where well over 400 inmates take their lives each year (Hayes, 1989). The rate
of suicide in county jails is estimated to be approximately four times greater
than that of the general population (Mumola, 2005). Overall, most jail suicide
victims were young white males who were arrested for nonviolent offenses and
intoxicated on arrest. Many were placed in isolation and dead within 24 hours
of incarceration (Hayes, 1989; Davis & Muscat, 1993). The overwhelming
majority of victims are found hanging by either bedding or clothing. Research
specific to suicide in urban jail facilities provides certain disparate findings.
Most victims of suicide in large urban facilities are arrested for violent
offenses and are dead within 1 to 4 months of incarceration (DuRand, Burtka,
Federman, Haycox, & Smith, 1995; Marcus & Alcabes, 1993). Due to the
extended length of confinement prior to suicide, intoxication is not always
the salient factor in urban jails as it is in other types of jail facilities. Suicide
victim characteristics such as age, race, gender, method, and instrument
remain generally consistent in both urban and nonurban jails.
While suicide is well recognized as a critical problem within jails, the
issue of prison suicide has not received comparable attention, perhaps
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). Although the rate of suicide in
prison is considerably lower than in jail, it still remains slightly greater than
the general population (Mumola, 2005). Most research on prison suicide
has found that the vast majority of victims were convicted of personal
crimes, housed in single cells (often either administrative or disciplinary
segregation), and have histories of prior suicide attempts and/or mental
illness (Daniel & Fleming, 2006; He, Felthous, Holzer, Nathan, & Veasey,
2001; Kovasznay, Miraglia, Beer, & Way, 2004; Salive, Smith, & Brewer,
1989; White, Schimmel, Frickey, 2002).
The precipitating factors of suicidal behavior in jail are well established
(Bonner, 1992, 2000). It has been hypothesized that two primary causes for jail
suicide exist: (1) jail environments 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 may enhance suicidal behavior: fear of the

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unknown, distrust of authoritarian environment, lack of apparent control over
the future, isolation from family and significant others, shame of incarceration,
and the 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 use of drugs, recent loss of
stabilizing resources, severe guilt or shame over the alleged offense, current
mental illness, prior history of suicidal behavior, and an approaching court date.
Some inmates simply are (or become) ill-equipped to handle the common
stresses of confinement. As the inmate reaches an emotional breaking point,
the result can be suicidal ideation, attempt, or completion. During initial
confinement in a jail, this stress can be limited to fear of the unknown and
isolation from family, but over time (including stays in prison) stress may
become exacerbated and include loss of outside relationships, conflicts within
the institution, victimization, further legal frustration, physical and emotional
breakdown, and problems of coping within the institutional environment
(Bonner, 1992). Precipitating factors in prison suicide may include new legal
problems, marital or relationship difficulties, and inmate-related conflicts
(White et al., 2002).
Despite a declining rate of suicide in county jails throughout the country,
there remains the lingering problem of too many preventable suicides occurring
alongside the feeble attempt to comprehensively review the deaths through a
mortality review process. The thorough examination of an inmate death,
encompassing both a mortality review and psychological autopsy, is cited in
most national standards. For example, according to National Commission on
Correctional Health Care (NCCHC) standards, “a clinical mortality review is
an assessment of the clinical care provided and the circumstances leading up
to a death” (NCCHC, 2003). In many cases, however, the clinical mortality
review is simply a review of the inmate’s chart by a physician. A national
survey of suicide prevention practices in state prison systems found that only
14% of departments of correction addressed the issue of administrative or
mortality reviews in their suicide prevention policy or other administrative
directive (Hayes, 1995).
NCCHC standards also recommend a “psychological autopsy,” in which
a psychologist or other qualified mental health professional conducts “a
written reconstruction of an individual’s life with an emphasis on factors that
may have contributed to the individual’s death” (NCCHC, 2003). Although
there are various references to psychological autopsies for inmate suicides
in the literature (Aufderheide, 2000; Sanchez, 2006), the process is often
misunderstood and misused within the correctional environment. Finally, the
Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
offers guidance through policies and procedures for the “root cause analysis,”
but it too is rarely found within the correctional facilities (JCAHO, 2005).
According to JACHO:
Root cause analysis is a process for identifying the basic and causal factors that
underlie variation in performance, including the occurrence or possible occurrence of
a sentinel event. A root cause analysis focuses primarily on systems and processes, not
on individual performance. It progresses from special causes in clinical processes to
common causes in organizational processes and identifies potential improvements in
processes or systems that tend to decrease the likelihood of such events in the future, or
determines, after analysis, that no such improvement opportunities exist. (p. 2)

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Lindsay M. Hayes

In order to fully understand why an inmate committed suicide, as well
as whether the correctional facility was in the best possible position
to prevent the incident, every suicide and serious suicide attempt (i.e.,
requiring hospitalization) should be examined through a comprehensive
mortality review process. The process is separate and apart from other
formal investigations that may be required to determine the cause of death
(e.g., medical examiner’s autopsy, departmental investigation, state police
inquiry, coroner’s inquest).
The primary purposes of a mortality review are: What happened in the
case under review and what can be learned to help prevent future incidents?
Unlike NCCHC requirements which stress only a clinical perspective, the
mortality review team must be multidisciplinary and include representatives
of both line and management level staff from the corrections, medical, and
mental health divisions. Exclusion of one or more disciplines will severely
jeopardize the integrity of the review. The multidisciplinary review should
include: (1) critical review of the circumstances surrounding the incident;
(2) critical review of facility procedures relevant to the incident; (3) synopsis
of all relevant training received by involved staff; (4) review of pertinent
medical and mental health services/reports involving the victim; (5) review
of possible precipitating factors (i.e., circumstances which may have
caused the victim to engage in self-injury/suicide) resulting in the incident;
and (6) recommendations, if any, for change in policy, training, physical
plant, medical or mental health services, and operational procedures (Cox
& Hayes, 2003).
Most jail and prison facilities do not embark on a comprehensive and
multidisciplinary mortality review process. Why? There are concerns about
liability. There is the inherent awkwardness of discussing the circumstances
surrounding an inmate’s death across various disciplines within an agency.
But inevitably, mortality reviews are not conducted because key actors in the
process (i.e., the administrators) are afraid of what they may find. Take, for
example, the suicide of Edward Vaughn.
According to available records, 45-year-old Edward Vaughn (a pseudonym)
was first confined in the Lincoln County Jail on February 8, 2002, for
various charges, including alleged criminal attempt at kidnapping, unlawful
restraint, and aggravated assault.1 He was assessed as being both mentally
ill and suicidal soon after his confinement. During the intake process,
Mr. Vaughn became incoherent and it was determined that he had suffered
from an overdose of his psychotropic medication. A razor blade was later
found in his clothes. Mr. Vaughn was placed on suicide precautions with
the requirement of observation at 15-minute intervals. Two days later on
February 10, he was observed to be bleeding from self-inflicted lacerations
on his right wrist. He was provided treatment by nursing staff and remained
on suicide precautions with observation at 15-minute intervals. The
following day, Mr. Vaughn was observed with a noose around his neck
and tied to the cell bars. The ligature was removed and he remained on

1

In order to ensure complete confidentiality, certain identifying information regarding
the victim, facility, and staff have been changed. No modifications to the facts of the
case have been made.

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suicide precautions until February 25. On March 30, he was again placed
on suicide precautions with the requirement of observation at 15-minute
intervals for self-injurious behavior. He was also stripped naked and not
provided with any protective clothing (e.g., safety smock, paper gown).
Mr. Vaughn was released from the Lincoln County Jail on April 2, 2002.
Mr. Vaughn was again confined in the Lincoln County Jail on October
27, 2002 for charges that included alleged aggravated assault and reckless
endangerment. At the scene of arrest, he threatened suicide by placing a knife
to his throat. He also appeared depressed (“feeling so bad”) and threatened
suicide (“can’t live anymore”) during the intake process. Mr. Vaughn
self-reported a history of mental illness, psychiatric hospitalization, and
psychotropic medication. He also had observable scars from previous selfinflicted injuries. He was placed on suicide precautions in the reception unit
with the requirement of observation at 15-minute intervals. Several hours later,
Mr. Vaughn began to engage in self-injurious behavior by repeatedly throwing
himself on the floor and wall of his cell causing head trauma, and was placed
in a restraint chair and received psychotropic medication. He continued to
be observed as “quite tearful and depressed.” Mr. Vaughn was subsequently
removed from the restraint chair but remained on suicide precautions with
the requirement of observation at 15-minute intervals. The following day
(October 28), he was found hanging from the cell bars by a blanket that he
had torn into strips. Although the arriving nurse declared that “he’s gone,”
Mr. Vaughn remained conscious and was placed in a restraint chair after
continuing to threaten suicide. He was subsequently released from the restraint
chair, stripped naked without any protective clothing, and remained on suicide
precautions. On November 4, Mr. Vaughn was relocated to the mental health
unit and remained on suicide precautions until November 14. Although
Mr. Vaughn remained housed in the mental health unit, as a result of his
suicidal behavior, as well as assaultive behavior to staff, he was punished by
receiving a sanction of disciplinary segregation.
During the evening of December 4, 2002, Mr. Vaughn was requested to
change cells in the mental health unit. He refused, became very agitated,
and was forcefully removed from the unit and relocated in the segregation
unit at approximately 8:50 PM. After placement in his segregation cell,
Mr. Vaughn remained agitated and began to engage in various forms of
self-injurious behavior, including banging his head against the floor, bunk,
and wall; climbing on the top bunk and purposely falling off to the concrete floor; attempting to flush his head down the toilet; and trying to hang
himself by tying his underwear around his neck and to the towel bar in the
cell. He was again placed in a restraint chair.
A few hours later at approximately 12:30 AM on December 5, 2002,
Mr. Vaughn was released from the restraint chair and placed on suicide
precautions with the requirement of observation at 15-minute intervals. For
unexplained reasons, he was reportedly observed at 30-minute intervals
during the next several hours. Beginning at approximately 7:30 AM, the
officers’ logs reflected observation at exact 15-minute intervals. The last
documented observation of Mr. Vaughn on suicide precautions occurred at
4:00 PM on December 5, 2002. At approximately 4:16 PM, a correctional
officer found Mr. Vaughn hanging from the cell bars by a strip of bed sheet.
(According to the videotape recording of the housing unit and the suicide

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Lindsay M. Hayes

attempt, the last time that an officer was in the housing unit was approximately 3:45 PM and that officer did not walk past Mr. Vaughn’s cell. The
inmate was seen on the videotape to be tying the sheet to the cell bars at
3:56 PM and the sheet was visible from that time forward until he was found
hanging 20 minutes later at 4:16 PM.) The officer called for backup personnel and several correctional staff arrived shortly thereafter and assisted in
cutting the sheet away from the bars. The cell door was opened and Mr.
Vaughn was placed on the floor. Other correctional personnel arrived in the
housing area and stood around the victim. Approximately 3 minutes later at
4:19 PM, medical staff arrived and initiated cardiopulmonary resuscitation
(CPR). At approximately 4:29 PM, emergency medical services personnel
arrived and continued life-saving measures. Mr. Vaughn was then transported
to a local hospital and subsequently pronounced dead.
Why did Edward Vaughn commit suicide? What really happened? Was
he ever considered a high risk for suicide? Was he ever considered for
hospitalization? Was he on the correct level of observation? Why was he
stripped naked without any protective clothing? How was he able to gain
access to both a sheet and blanket? Was staff aware that Mr. Vaughn had
attempted suicide in the facility several months earlier? Why did correctional
officers wait until medical personnel arrived before assisting with CPR? Had
any personnel received suicide prevention training prior to the incident?
Was Mr. Vaughn’s suicide preventable? Were there any similarities between
his death and the other prior suicides in the facility? These and many other
lingering questions were left unanswered in this case, as well as in several
hundred other suicides that occur in correctional facilities each year, simply
because many agencies choose not to address them. While verifying the cause
of death and ruling out foul play remain the staples of routine investigations,
correctional agencies remain reluctant to comprehensively review an inmate
suicide, determine whether or not it was preventable, and take corrective
action to reduce the opportunity for similar deaths in the future.

What a Mortality Review Would Have Found
A departmental investigation was conducted following Edward Vaughn’s
suicide and concluded that he was at low to moderate risk for suicide and,
based on the facility’s adequate policies and procedures, the death was not
preventable. Although an NCCHC-accredited facility, a mortality review was
not conducted in Mr. Vaughn’s case. If a comprehensive mortality review had
been conducted, the following issues would have been raised.
First, there was overwhelming evidence to show that Edward Vaughn
was at a continuing high risk for suicide in the Lincoln County Jail, and
that continuing high risk was known to various medical, mental health,
and correctional personnel. This much was known: (1) he had a history
of mental illness, psychiatric hospitalization, and psychotropic medication; (2) he was observed to be depressed, agitated, incoherent, “quite
tearful” and crying, and displaying numerous self-inflicted injuries and scars;
(3) he self-reported both depression (“feeling so bad”) and suicidal ideation (“can’t live anymore”), as well as requested to remain in the restraint
chair when feeling the impulse to engage in suicidal behavior; and (4) he

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engaged in self-injurious behavior on at least seven separate occasions
(immediately prior to or) during his confinement:
●

●

●

●
●

●

●

on intake on February 8 when it was suspected that he overdosed on
psychotropic medication,
on February 10 when he was observed to be bleeding from lacerations on his
right wrist,
on February 11 when he was observed with a noose around his neck and tied
to the cell bars,
on March 30 when he was observed engaging in self-injurious behavior,
on October 27 when he repeatedly threw himself on the floor and wall of his
cell causing head trauma,
on October 28 when he was found hanging from the cell bars by a blanket
that he had torn into strips, and
on December 4 when he observed banging his head against the floor, bunk,
and wall; climbing on the top bunk and purposely falling off to the concrete
floor; attempting to flush his head down the toilet; and trying to hang himself
by tying his underwear around his neck and to the towel bar in the cell.

Despite Mr. Vaughn’s continuing high risk for suicide during his confinement
in the Lincoln County Jail, the response from staff was the following:
placement on 15-minute suicide precautions in various unsafe cells, periodic
assessment by contracted medical and mental health staff, psychotropic
medication, and periodic placement for a few hours in a restraint chair. These
responses were inadequate because Mr. Vaughn was permitted to continue to
engage in self-injury and ultimately committed suicide in the facility.
The Lincoln County Jail also had inadequate policies and practices in
the area of suicide prevention (particularly levels of observation and safe
housing) that were the proximate causes of Mr. Vaughn’s suicide. A written
suicide prevention policy is a prerequisite for running a correctional facility.
The importance of written policy in suicide prevention is clearly stated in the
American Correctional Association standards (2004): “A suicide-prevention
program is approved by the health authority and reviewed by the facility
or program administrator. It includes specific procedures for handling intake,
screening, identifying, and supervising of a suicide-prone inmate and is signed
and reviewed annually” (p. 64). In addition, the National Commission on
Correctional Health Care standards (2003) requires each jail to have a written
suicide prevention plan that includes the following components: training,
identification, referral, evaluation, housing, monitoring, communication,
intervention, notification, reporting, review, and critical incident debriefing.
The Lincoln County Jail’s suicide prevention policy stated that the facility
will “provide special, housing, increased levels of observation, and medical
restraint to those inmates who display self-destructive behavior.” Although
the policy referenced both ACA and NCCHC standards, it was not consistent
with those standards. For example, although national correctional standards
required an option for constant observation for actively suicidal inmates,
the Lincoln County Jail’s suicide prevention policy provided two levels of
observation for suicidal inmates: suicide precaution and close observation.
A review of the policy indicated little discernible difference between the two
supervision levels. In practice, inmates on suicide precaution status were
stripped naked of their clothing, all items (with the exception of a blanket)

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Lindsay M. Hayes

were removed from the cell, and they were observed “at irregular 15-minute
intervals (no more than 15 minutes between checks). The checks are staggered
so that there is no predictable pattern for the inmate to use in planning suicide.”
Of course, allowing an inmate to be stripped naked without any protective
clothing (e.g., safety smock, paper gown) is contrary to all national standards,
as well as human decency. Inmates on close observation status were allowed
to retain their clothing and other possessions and were observed at staggered
15-minute intervals. Thus, the only difference between the two levels was
the issue of clothing and possessions. Contrary to Lincoln County Jail policy,
Mr. Vaughn was observed for several hours on December 5 at 30-minute
intervals, and was rarely observed at staggered or “irregular” 15-minute intervals
while on either close observation or suicide precaution status. Instead, the
officers’ logs were recorded at exact 15-minute intervals.
Despite his continuing high risk for suicide, Mr. Vaughn was never placed
on constant observation. Although observation at 15-minute intervals is
routinely reserved for inmates assessed as being either at low or moderate
risk for suicide, it should never be utilized for a highly suicidal individual.
In fact, Lincoln County Jail staff was emphatically warned of Mr. Vaughn’s
high-risk suicidal behavior when, on his discharge from the emergency room
of a local hospital on October 27, 2002, the physician stated: “Be absolutely
watchful of his behavior. Consider this patient high-risk for repeated self-injury.
Must have someone watching him at all times.” A review of the records in
this case indicated that facility staff never placed Mr. Vaughn on constant
observation nor considered psychiatric hospitalization for his continuing
high-risk suicidal behavior.
Further, interviews with jail staff revealed that even the alleged observation
of Mr. Vaughn at 15-minute intervals was not always performed by an
officer physically walking past his cell, but rather by an officer stationed
inside the control booth which was estimated to be between 30 and 40 feet
from Mr. Vaughn’s cell and partially obstructed by a stairway. A consulting
psychiatrist at the Lincoln County Jail later stated it would be improper
for a control booth officer to be responsible for the observation of suicidal
inmates, and that he was unaware that such a practice was occurring at the
Lincoln County Jail. In fact, the last time that an officer was in Mr. Vaughn’s
housing unit on December 5 was at approximately 3:45 pm, and that officer
did not walk past Mr. Vaughn’s cell. The inmate was seen on a videotape to
be tying the sheet to the cell bars at 3:56 pm and the sheet was visible from
that time forward until he was found hanging 20 minutes later at 4:16 pm. It
was obvious that none of the officers assigned to the housing unit (including
the control officer) adequately observed Mr. Vaughn prior to his death, the
proximate cause of which was his ability to successfully commit suicide. In
essence, had jail staff followed standard correctional practices and national
correctional standards, Mr. Vaughn would have been observed on constant
observation following his most recent high-risk self-injurious behavior
on December 4 and not had the ability to successfully commit suicide the
following day.
With regard to housing of suicidal inmates, consistent with national
correctional standards and standard practices in correctional facilities
throughout the country, housing assignments should be based on the ability
to maximize staff interaction with the inmate, avoiding assignments that

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heighten the depersonalizing aspects of incarceration. Ideally, suicidal inmates
should be housed in the general population, mental health unit, or medical
infirmary, located close to staff. All cells designated to house suicidal inmates
should be suicide-resistant, free of all obvious protrusions, and provide full
visibility. These cells should contain tamperproof light fixtures and ceiling
air vents that are protrusion-free. No cell housing a suicidal inmate should
have open-faced bars. Rather, each cell door should contain a heavy gauge
Lexan (or equivalent grade) glass panel that is large enough to allow staff a
full and unobstructed view of the cell interior. Cells housing suicidal inmates
should not contain any electrical switches or outlets, bunks with holes and
ladders, towel racks on desks and sinks, radiator vents, corded telephones of
any length, clothing hooks (of any kind), or any other object that provides an
easy anchoring device for hanging (Hayes, 2003). As reiterated in the NCCHC
standards, “All cells or rooms housing suicidal inmates are as suicide-resistant
as possible (e.g., without protrusions of any kind that would enable the inmate
to hang himself/herself)” (p. 102).
Although Lincoln County Jail’s suicide prevention policy required “special
housing” for suicidal inmates, the policy did not contain any description as
to the specific type of housing provided to such inmates. As such, suicidal
inmates could be placed in a variety of housing units, each of which
contained open-faced bars, shelves with clothing hooks, metal bunks with
holes, and towel racks attached to desks. In Mr. Vaughn’s case, he was placed
on suicide precautions in the reception, mental health, and segregation units,
and he was able to attempt suicide in each of these units. For example, he
was found hanging from the cell bars in the reception unit on October 28,
tried to hang himself from the towel bar attached to the desk in his cell in
the segregation unit on December 4, and successfully committed suicide by
hanging himself from the cell bars on December 5. For inexplicable reasons,
Mr. Vaughn was also able to attempt (and commit) suicide with ligatures that
were prohibited from being in his cell, including a blanket and sheet. The
communication between corrections, medical, and mental health personnel at
the facility was so poor that an officer gave Mr. Vaughn a blanket and sheet
because he did not realize the inmate was on suicide precautions.
Given the fact the inmates have historically attempted and/or committed
suicide in the Lincoln County Jail utilizing a variety of dangerous anchoring
devices (including a successful suicide by hanging of an inmate utilizing a
shelf with clothing hooks in July 1995 and a hanging attempt of an inmate
utilizing the open-faced bars in February 2000), it is particularly troubling
that Mr. Vaughn was placed in a cell on suicide precautions that contained
protrusions that were obvious and previously known to be dangerous by jail
officials. In fact, the Lincoln County Jail had a policy that required a suicidal
inmate to be placed in a dangerous cell (i.e., “Suicide Precaution: This
involves the inmate in an open-barred cell”).
Although heavy gauge Lexan (or equivalent grade) glass paneling is
commonly known and utilized in jail and prison facilities throughout the
country to cover bars of cells housing suicidal inmates, when Lincoln
County Jail officials were subsequently asked why Lexan paneling was not
installed on the barred doors of cells in the facility, they offered inadequate
responses, ranging from not having heard of Lexan paneling to the belief
that inmates would smear feces on the paneling thus obstructing visibility.

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Lindsay M. Hayes

Jail officials had several options to safely house suicidal inmates, including
the placement of Lexan (or equivalent grade) glass paneling on selective
cells, housing suicidal inmates in cells that did not have open-barred doors,
and ensuring that actively suicidal inmates were provided with constant
observation of a correctional officer who was stationed directly outside the
cell. Instead, jail officials chose none of these or other options and simply
continued to allow these obviously dangerous cells to be utilized for housing
suicidal inmates.
Finally, although the Lincoln County Jail’s 4-hour “In-Custody Suicide
Prevention” training lesson plan appeared comprehensive, a review of
personnel files revealed that the workshop was offered at 1-hour (not 4-hour)
durations and, contrary to both ACA and NCCHC standards, most personnel
who interacted with Mr. Vaughn either never received suicide prevention
training or received it infrequently from 1995 through 2002.

Conclusion
Although national standards address the issue of mortality reviews in varying
degrees, practical guidelines for conducting meaningful reviews are absent.
Based on the critical components of a comprehensive suicide prevention
program (Hayes, 2005), detailed below is a recommended format and areas of
inquiry for conducting a morbidity–mortality review.
1. Training
Had all correctional, medical, and mental health staff involved in the
incident received both basic and annual training in the area of suicide
prevention prior to the suicide?
Had all staff who responded to the incident received training (and were
currently certified) in standard first aid and cardiopulmonary resuscitation
(CPR) prior to the suicide?
●

●

2. Identification/Referral/Assessment
Upon this inmate’s initial entry into the facility, were the arresting/
transporting officer(s) asked whether they believed the inmate was at risk
for suicide? If so, what was the response?
Had the inmate been screened for potentially suicidal behavior on entry
into the facility?
Did the screening form include inquiry regarding: past suicidal ideation
and/or attempts; current ideation, threat, plan; prior mental health treatment/
hospitalization; recent significant loss (job, relationship, death of family
member/close friend, etc.); and history of suicidal behavior by family
member/close friend?
If the screening process indicated a potential risk for suicide, was the
inmate properly referred to mental health and/or medical personnel?
Had the inmate received a postadmission mental health screening within
14 days of his/her confinement?
Had the inmate previously been confined in the facility/system? If so,
had the inmate been on suicide precautions during a prior confinement in the
facility/system? Was such information available to staff responsible for the
current intake screening and mental health assessments?
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3. Communication
Was there information regarding the inmate’s prior and/or current suicide risk
from outside agencies that was not communicated to the correctional facility?
Was there information regarding the inmate’s prior and/or current suicide
risk from correctional, mental health, and/or medical personnel that was
not communicated throughout the facility to appropriate personnel?
Did the inmate engage in any type of behavior that might have been
indicative of a potential risk of suicide? If so, was this observed behavior
communicated throughout the facility to appropriate personnel?
●

●

●

4. Housing
Where was the inmate housed and why was he/she assigned to this housing unit?
If placed in a “special management” (e.g., disciplinary and/or administrative segregation) housing unit at the time of death, had the inmate received
a written assessment for suicide risk by mental health and/or medical staff
on admission to the special unit?
Was there anything regarding the physical design of the inmate’s cell
and/or housing unit that contributed to the suicide (e.g., poor visibility,
protrusions in cell conducive to hanging attempts)?
●

●

●

5. Levels of Supervision
What level and frequency of supervision was the inmate under immediately prior to the incident?
Given the inmate’s observed behavior prior to the incident, was the level
of supervision adequate?
When was the inmate last physically observed by correctional staff prior
to the incident?
Was there any reason to question the accuracy of the last reported
observation by correctional staff?
If the inmate was not physically observed within the required time interval
prior to the incident, what reason(s) was determined to cause the delay in
supervision?
Was the inmate on a mental health and/or medical caseload? If so, what
was the frequency of contact between the inmate and mental health and/or
medical personnel?
When was the inmate last seen by mental health and/or medical personnel?
Was there any reason to question the accuracy of the last reported
observation by mental health and/or medical personnel?
If the inmate was not on a mental health and/or medical caseload, should
he/she have been?
If the inmate was not on a suicide watch at the time of the incident, should
he/she have been?
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●

●

●

●

●

●

6. Intervention
Did the staff member(s) who discovered the inmate follow proper
intervention procedures, i.e., surveyed the scene to ensure the emergency
was genuine, called for backup support, ensured that medical personnel
were immediately notified, and initiated standard first aid and/or CPR?
●

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Lindsay M. Hayes
●

●

Did the inmate’s housing unit contain proper emergency equipment for
correctional staff to effectively respond to a suicide attempt, i.e., first aid
kit, gloves, pocket mask, mouth shield, or Ambu bag, and rescue tool (to
quickly cut through fibrous material)?
Were there any delays in either correctional or medical personnel
immediately responding to the incident? Were medical personnel properly
notified as to the nature of the emergency and did they respond with
appropriate equipment? Was all the medical equipment working
properly?

7. Reporting
Were all appropriate officials and personnel notified of the incident in a
timely manner?
Were other notifications, including the inmate’s family and appropriate
outside authorities, made in a timely manner?
Did all staff who came into contact with the inmate prior to the incident
submit a report and/or statement as to their full knowledge of the inmate
and incident? Was there any reason to question the accuracy and/or completeness of any report and/or statement?
●

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8. Follow-Up/Morbidity–Mortality Review
Were all affected staff and inmates offered critical incident stress debriefing following the incident?
Were there any other investigations conducted (or that should be authorized) into the incident that may be helpful to the morbidity–mortality
review?
As a result of this review, were there any possible precipitating factors
(i.e., circumstances which may have caused the victim to commit suicide) offered and discussed?
Were there any findings and/or recommendations from previous reviews
of inmate suicides that are relevant to this morbidity–mortality review?
As a result of this review, what recommendations (if any) are necessary
for revisions in policy, training, physical plant, medical or mental health
services, and operational procedures to reduce the likelihood of future
incidents?
●

●

●

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