Evaluation of Issues Surrounding Inmate Deaths in Federal Bureau of Prisons Institutions

Submitting OIG:

Department of Justice OIG

Date Issued:

Thursday, February 15, 2024

Agency Reviewed / Investigated:

Department of Justice

Submitting OIG-Specific Report Number:

24-041

Component, if applicable:

Federal Bureau of Prisons

Location(s):

Agency-Wide

Type of Report:

Inspection / Evaluation

Questioned Costs:

Funds for Better Use:

Number of Recommendations:

Report updated under NDAA 5274:

View Document:

Attachment	Size
24-041.pdf	4.23 MB

Recommendation Number	Recommendation Status	Significant Recommendation	Additional Details
1	Open	No	https://oig.justice.gov/reports
Develop strategies to ensure that staff assign accurate, consistent, and timely Mental Health Care Level designations to inmates.
2	Open	No	https://oig.justice.gov/reports
Ensure that all institutions conduct required mock suicide drills, and develop strategies to increase staff participation in those drills.
3	Open	No	https://oig.justice.gov/reports
Ensure that all appropriate staff are trained in automated external defibrillator use and that automated external defibrillators are strategically placed, readily available, and regularly checked to ensure that they are in working order at each BOP institution.
4	Open	No	https://oig.justice.gov/reports
Ensure that cut-down tools in working order are accessible to staff in each housing unit at each institution, that staff are trained on proper use of the tool, and that the BOP determines whether staff should be issued and required to keep their own cut-down tool on their duty belt during their entire shift.
5	Open	No	https://oig.justice.gov/reports
Ensure that each institution has a sufficient number of maneuverable gurneys in strategic locations to provide proper medical response during inmate transport.
6	Open	No	https://oig.justice.gov/reports
Issue standard, enterprise-wide guidance and training to staff on using the radio to communicate clear, descriptive information during inmate medical emergencies.
7	Open	No	https://oig.justice.gov/reports
Ensure that staff receive both the initial and refresher naloxone training and are fully prepared to administer naloxone to an unresponsive inmate suspected of having experienced a drug overdose.
8	Open	No	https://oig.justice.gov/reports
Ensure that all Evidence Recovery Teams are properly trained on post-incident evidence recovery protocols.
9	Open	No	https://oig.justice.gov/reports
Develop procedures to ensure that all required death-related records are completed and collected consistently and in accordance with established deadlines.
10	Open	No	https://oig.justice.gov/reports
Assess the benefit and feasibility of expanding its policy requiring After Action Reviews to include reviews of all inmate homicides and deaths by accidental and unknown factors, not just for inmate suicides.

Recommendation Number

Recommendation Status

Significant Recommendation

Additional Details

Open

https://oig.justice.gov/reports

Develop strategies to ensure that staff assign accurate, consistent, and timely Mental Health Care Level designations to inmates.

Open

https://oig.justice.gov/reports

Ensure that all institutions conduct required mock suicide drills, and develop strategies to increase staff participation in those drills.

Open

https://oig.justice.gov/reports