LEADERSHIP PERSPECTIVES:
PREVENTION OF IN-CUSTODY DEATHS
Fred Meyer, MA, CJM, CCHP
There are few things jail administrators dread more than the phone call that there’s been a death in their facility. While jail populations have been declining over the past decade, the number of in-custody deaths has been on the rise. There are many factors that influence these numbers and I suspect we can all agree that the inmate population is disproportionately impacted by individual-level risk factors such as substance abuse, as well as acute and chronic medical and mental health conditions. Each death is a tragedy and it’s important to recognize the impacts these events have on families, as well as correctional staff and medical personnel working the line. Prevention and mitigation of in-custody death should be a primary leadership strategy for every jail operation.
The Sanctity of Life Should Be At the Forefront
A focus on de-escalation tactics has been a mantra of many jail leaders over the past decade. Those working in the profession understand how difficult it is to manage the incarcerated population and prevent adverse events from occurring. The structured jail environment is unique, in that individuals arrested often come into the facility angry, under the influence, and with a substantial number of health-related problems. Nowhere else are people forced to adhere to rigid rules, immediately discontinue use of any intoxicating substance, and answer personal medical and mental health questions. These individual- and institutional-level factors have the potential to create circumstances that place staff and inmates at risk in many ways, the worst of which includes attacks on staff or deaths in custody.
There are five causes that medical examiners use when investigating the cause of death: natural, accidental, suicide, homicide, or undetermined. While any of these may occur, correctional leaders often focus upon homicide and suicide as the primary risks that need to be mitigated. This may discourage staff from looking for ways to prevent death from other causes. A death by natural or accidental causes may be preventable as well.
Policy and Training
Policy and training are critical when we work to reduce in-custody deaths in our jails. Agencies should thoroughly review their current policies at least annually to ensure they include the most current strategies and tactics in all critical areas. This review should include the input of experts from the relevant field (e.g., medical, mental health, legal, etc.). It is important to question whether current policy reflects best practices and adheres to nationally accepted standards. Your county or state may have laws that change and voluntary accreditation through the National Commission on Correctional Health Care is one option to ensure that you are keeping up with changes in the industry related to inmate health care.
Formal training in the academy and field training should be followed up with annual in-service training. When we invest in our people and ensure they are trained, the risk of adverse events is reduced. Training needs to go beyond use of force and de-escalation techniques. At this point, identification of health risks during force application should be commonplace in training. Restraint and control techniques should be up to date and staff should be aware of the risks associated with prone restraint and the use of restraint chairs or beds. Suicide prevention should include risk factors, proactive management, referrals, and appropriate response to inmates in crisis.
Using an interdisciplinary approach that includes instructors and formalized information from the medical and mental health professions should be included. There is always room for improvement and being informed by experts in the medical and mental health fields will improve your policies, your training, and your overall operation.
Collaboration
Collaboration is essential to reducing the risk of in-custody deaths. The incarcerated population has changed dramatically
over the past several years with suicide risks, the opioid crisis, and alcohol withdrawal risks presenting a greater risk than ever. Through intake screening processes, we hope to identify those at risk of detoxification and those with significant mental health and behavioral issues. There is also a need to identify any other acute or chronic medical conditions at this early stage in the process.
Corrections staff should be able to identify changes in looks and behavior that can be relayed to medical staff. In order to ensure appropriate treatment is provided, there needs to be communication at all levels between custody and medical. Clinical autonomy for treatment decisions is mandatory, those decisions can be informed by the observation of correctional staff who are alert and proactive. Corrections officers have more interaction with the population than anyone and they are extraordinarily perceptive; their input can save lives.
When there is an in-custody death, there needs to be a clinical mortality review. This is a thorough evaluation of all factors prior to, during, and following the incident by medical. This is critical to determine the appropriateness of care given; whether policies, procedures, and processes need to be changed; and to identify areas for improvement or further study. It is imperative to explore what happened medically and if there is anything, at any point, which could have been done differently to prevent or mitigate this event and prevent similar deaths from happening in the future. In the case of a completed suicide, a psychological autopsy should also be performed by mental health. This is a thorough record review, examination of the suicide site, and interviews with staff and inmates familiar with the deceased.
This should be followed by an administrative review that includes custody and medical leadership. This meeting will focus on an evaluation of the incident and facility procedures, custody staff training and emergency response, and medical and mental health actions prior to, during, and after the event. Emphasis should be placed on looking for, any helpful changes to policy, procedures, physicals, plant, and operations. These reviews are not designed to place blame, rather, to fill any gaps and improve operations in the future. They are not criminal or internal affairs investigations but performance improvement meetings.
Leadership Starts With You
I stole this phrase from one of my mentors many years ago. No matter your rank or position in life, you impact and influence others, often much more than you understand. Officers and nurses work in a demanding and dangerous environment managing individuals who have been legally deprived of their freedom. Corrections professionals are not recognized as they should be in the public arena and the stresses of the job can weigh on even the toughest people. Officers that have a good working relationship with medical personnel are much more effective. Inmates that receive effective medical and mental health care are less likely to attack staff. Working together bridges gaps in security and health care.
Individuals who hold rank can influence every aspect of a jail operation and can drive change for the better (or worse). It is said that police culture is tough to change, in my experience, corrections is at least that tough if not more so. In my experience, proactive leadership can overcome nearly any obstacle. If you are an administrator, meet regularly with medical and mental health administration and ensure your mid-level managers are doing the same with charge nurses and supervisors. Find out what is working and what problems are emerging, drive discussions and tactics to improve. Ensure there is data to effectively identify problems and determine corrective actions (e.g., bookings, ER send outs, sick call and transport delays, medication distribution issues, medical staffing shortages, inmate grievances, etc.). Once a problem is found, ensure that a tactic is employed to mitigate the issue and demand that the problem is addressed at each subsequent meeting in an effort to implement continuous quality improvement. I suggest interdisciplinary meetings be held monthly, no less than quarterly.
If you have brass on your collar, get involved and communicate, manage by walking around and people will follow you. Look for
solutions to problems and do something to implement them. It is your ship, manage by walking around as much as possible. Ask questions and if you find an issue, fix it. If you are a floor supervisor, talk with your officers (and various medical line staff) regularly about the importance of the sanctity of life, proactive inmate management, policy changes, and collaboration with medical. Memorialize your actions and stay focused on your people, you are their most immediate resource. Officers, understand the valuable service that medical and mental health professionals provide. When you work together, fewer critical incidents will occur, and you will have less risk and stress each day.
Conclusion
It is more important than ever for jail and medical professionals to work collaboratively to predict, prevent, and mitigate health and suicide risks among the inmate population. Leadership starts with you, open up and take a critical look at your operation. Every agency that I have worked with, to include my own, found multiple gaps to fill and efficiencies to implement. Having regular meetings to keep identifying problems, implementing tactics, and evaluating outcomes will improve your operation. As solutions are found, new challenges will arise, and you will be prepared to take them on effectively.
There are several resources available to assist you and your agency with this and other performance improvement initiatives. If you have questions, the American Jail Association and the National Commission on Correctional Health Care are willing to help and can provide additional information. Thank you all for the noble and heroic work you do each day. Be proud and know that your efforts are important, recognized, and appreciated. Stay safe and healthy!
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Fred W. Meyer, MA CJM, CCHP is a retired deputy chief and currently managing director of the consulting arm of the National Commission on Correctional Health Care. He has over 25 years of experience in corrections and is a graduate of the National Jail Leadership Command Academy and Jail Executive Development Program. He holds a Master’s degree in Criminal Justice from the University of Nevada, Las Vegas. For more information, he can be reached at fredmeyer@ncchcresources.org