A Blistering Report on Hundreds of Preventable Inmate Deaths in the Federal Prison System

The Federal Bureau of Prisons (BOP) system, which houses approximately 157,000 inmates and is staffed by around 35,000 employees, has been under scrutiny for years due to staffing shortages, turnover, and a lack of adequate healthcare and mental health services. A recent report by the Justice Department’s Office of the Inspector General (OIG) has shed light on the systemic failures that contributed to hundreds of preventable inmate deaths between 2014 and 2021.

The OIG report examined 344 deaths of inmates in BOP’s custody that were the result of suicides, homicides, or accidents, excluding health care-related deaths. More than half of these deaths, 187 or 54%, were by suicide. The report identified several recurring factors in the population that died by suicide, including their status as sex offenders, the length of their sentences, and mental health struggles.

The report found that failures to adequately screen for and monitor mental health issues, as well as deficiencies in caring for those identified as at-risk, likely contributed to the suicides. Notably, the vast majority of suicides, 118 out of 187, occurred among inmates who were deemed to have no mental health issues, highlighting the lack of accurate and consistent testing and treatment in the facilities.

One instance described in the report involved an inmate who attempted suicide prior to arriving at a BOP facility and was housed alone in a single cell, without follow-up care for seven days. The individual later died by suicide. The inspector general noted that inmates held in single cells were more likely to take their own lives due to the increased opportunities for suicide.

Communication breakdowns and violations of longstanding policies, such as cell check-ins, also contributed to the suicides. BOP staff are required to conduct mock suicide drills to better respond to and prevent inmate deaths. However, an average of 72% of facilities lacked documentation showing they conducted the three required tests.

Improper documentation, short staffing, and a failure to follow federal policy were identified as trends in the report. In about 30 of the 344 deaths, understaffing was identified as a factor. BOP personnel were unable to produce proper documentation related to 43% of the inmate deaths. During a 2022 visit to U.S. Penitentiary Thomson in Illinois, investigators found that the facility had not had an on-site, full-time physician on staff for more than a year, and nearly half of its nursing jobs were vacant.

The federal prison system has been plagued for years by staffing shortages and turnover. Inmates in BOP custody are most commonly incarcerated for immigration, drugs, firearms, or white-collar crimes. The most violent offenders in the U.S. are typically held in state or local penitentiaries, as homicides and many violent crimes are not federally prosecuted. Nearly 93% of federal inmates are men.

The report found that prisons with higher security levels experienced a higher percentage of inmate deaths. The report found that 113 of the 187 suicides occurred in medium- or high-security facilities, and 59 of the 89 homicides happened in high-security prisons.

The BOP has come under increased scrutiny following the deaths of several high-profile inmates in its custody. A 2023 inspector general report found that staff misconduct allowed disgraced New York financier Jeffrey Epstein to kill himself in 2019. In 2022, the Justice Department watchdog found that the prison death of notorious Boston mob boss James “Whitey” Bulger was the result of inadequate medical evaluations and intelligence gaps by BOP personnel.

Illegal contraband and drugs also greatly contributed to inmate deaths. Nearly one-third of the 344 deaths involved drugs or weapons, such as makeshift knives, razors, or ropes. Seventy-nine inmates died from overdoses caused by either contraband drugs or the improper use of prescription medications. The inspector general found that proper protocol was not followed in at least five drug overdose deaths in which the life-saving naloxone could have made a difference.

The report recommended various steps BOP leadership should take to remedy the dismal findings, including developing strategies to improve health care designations of inmates, ensuring all staff are trained on defibrillator use and other life-saving practices, and improving documentation when deaths do occur. BOP Director Collette Peters concurred with the recommendations and acknowledged the tragic nature of unexpected deaths among those in their care.

The report serves as a stark reminder of the urgent need for reforms in the federal prison system to address the systemic failures that have contributed to hundreds of preventable inmate deaths. The BOP must prioritize addressing the unique health challenges, including mental health and substance use disorders, faced by individuals in custody to prevent future tragedies.

If you or someone you know is in emotional distress or a suicidal crisis, you can reach the 988 Suicide & Crisis Lifeline by calling or texting 988. You can also chat with the 988 Suicide & Crisis Lifeline here. For more information about mental health care resources and support, The National Alliance on Mental Illness (NAMI) HelpLine can be reached Monday through Friday, 10 a.m.–10 p.m. ET, at 1-800-950-NAMI (6264) or email info@nami.org.