A Justice Department Inspector General report published Thursday found a “combination of recurring policy violations and a multitude of operational failures” contributed to nearly 200 inmate suicides at Federal Bureau of Prisons locations between 2014 and 2021, days after the bureau’s director laid out a strategy to address agency-wide issues.
More than half died by suicide, according to the report.
Led by Justice Department Inspector General Michael Horowitz, the 111-page report evaluated 344 inmate deaths, 187 of which were suicides, from fiscal years 2014 to 2021.
The report, which evaluated four categories of death, found “several operational and managerial deficiencies” created unsafe conditions surrounding a number of the deaths—with a “combination of recurring policy violations and a multitude of operational failures at institutions” contributing to inmate suicides, which accounted for the most deaths during the report’s scope.
Homicides were the second-most-common form of inmate death, according to the report, accounting for 89 deaths—followed by accidental deaths (56) and deaths with unknown causes (12).
Bureau of Prisons spokesman Scott Taylor told Forbes in an email that the agency “has already taken substantial steps”—indicated at the end of the report—to mitigate inmate deaths and views the OIG’s recommendations as an “opportunity to enhance our ongoing efforts in addressing the health and well-being” of inmates.
To address the issues, the report made 12 recommendations for the agency including developing strategies to assign “accurate, consistent and timely” Mental Health Care Level designations to inmates and conducting mock suicide drills across all institutions. The BOP agreed with all recommendations.
“We are dedicated to implementing these changes to ensure the safety and well-being of those in our custody,” Taylor said.
“Operational and management challenges” at BOP facilities that may have contributed to high-profile inmate deaths, including James “Whitey” Bulger’s 2018 homicide and Jeffrey Epstein’s 2019 suicide, have been scrutinized in recent years, according to the report. Two previous reports, issued in 2022 and 2023, respectively, analyzed the deaths of Bulger and Epstein. Additionally, the OIG has also completed broader evaluations into the challenges of BOP operations. Lawmakers and prison advocacy groups alike have previously pushed for better conditions across BOP institutions.
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