Reducing Inmate Suicides through the Mortality Review Process

Abstract

Suicide continues to be a leading cause of death in jail and prison systems across the country. The current mortality review process for these deaths is fraught with challenges, including concerns about liability and possible disclosure of the process to outside parties, as well as the inherent awkwardness of discussing the suicide across various disciplines within an agency and/or with an outsider healthcare contractor. As a result, many inmate suicides result in no review, cursory medical chart reviews, or disparate “silo” reviews by a correctional agency and healthcare contractor, resulting in possible finger-pointing between the entities or incorrect conclusions that the death was not preventable. A meaningful mortality review for an inmate suicide addresses the basic questions of what happened in the time leading up to, and including the death, and what can be learned to prevent future incidents. The review should not be limited to a clinical perspective of the death, rather, it must be multidisciplinary and include representatives of both line and management level staff from the corrections, medical, and mental health divisions. The review should include opportunities for improvement, that is, corrective action plans that identify specific deficiencies, responsible party(ies) to address deficiencies, deadlines for completion, and continuous quality improvement to ensure that corrective action is maintained. Practical guidelines for conducting meaningful, multidisciplinary mortality reviews are offered.