Report: Wash. DOC needs to do more to prevent inmate suicides

“Suicides are preventable. There should be zero, that should be the goal," said the investigation's author

By Sarah Sinning

OLYMPIA — While inmate suicides fell last year in Washington State prisons, the state DOC could still be doing more to prevent inmates from self-harming.

That's according to a report released Monday from the state's Office of Corrections Ombuds, Oregon Public Broadcasting reports

Citing the cases of two inmates who died by suicide in 2020, the report makes several recommendations for improvement, including ensuring that Suicide Risk Assessments and Mental Health Safety Plans are always completed as per policy and improving the communication between custody and health services staff so that signs of mental health distress are managed properly and in a timely manner. 

The report notes that one of the inmates was repeatedly punished for "behaviors that most would identify as being related to mental illness" and that disciplinary action was taken "without any consultation with mental health" staff. 

The report also notes that in both of the cases, the AED used for resuscitation malfunctioned, with nursing staff in one case lacking sufficient training in proper resuscitative technique.

“Suicides are preventable. There should be zero, that should be the goal,” said Dr. Patricia David, the investigation’s author and the OCO’s Director of Patient Safety and Performance Review.

In her response to the report, DOC Acting Secretary Julie Martin agreed. Though she pointed out that the rate of suicide among incarcerated individuals in the state has been less than half the national average over the past few years, "one death by suicide is too many," she said.

Many of the suggested improvements, however, are easier said than done. While the report recommends a review of "the current mental health screening process to achieve a staffing level that allows a more reasonable daily caseload, so that staff can perform a thorough review of medical documents accompanying new intakes," Martin acknowledges that this isn't a simple hiring fix. 

By state law, she points out, the prison system must receive new inmates within seven days of their sentencing, which means that on some days, busloads of inmates arrive one after another, putting significant pressure on staff to process the new intakes as quickly as possible.

[Next: 10 warning signs of suicidal inmates]

Review the full 15-page report with the DOC's response:

2020 Suicides in Custody Final With DOC Response by PG Edi on Scribd

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