The scathing report found mental health care, emergency responses and the detection of contraband drugs and weapons were all lacking.
WASHINGTON — The kind of systemic failures that enabled the high-profile prison deaths of notorious gangster Whitey Bulger and financier Jeffrey Epstein also contributed to the deaths of hundreds of other federal prisoners in recent years, a watchdog report released Thursday found.
Mental health care, emergency responses and the detection of contraband drugs and weapons all are lacking, according to the latest scathing report to raise alarms about the chronically understaffed, crisis-plagued federal Bureau of Prisons.
The agency said it’s already taken “substantial steps” toward reducing preventable deaths, though it acknowledged there’s a need for improvements, including in mental heath care assessments.
More than half of the 344 deaths over the course of eight years were suicides, and Justice Department watchdog investigators found policy violations and operational failures in many of those cases. That included inmates who were given potentially inappropriate mental health assignments and those who were housed in a single cell, which increases the risk of suicide.
In one-third of suicide cases, the report found staff did not do sufficient checks of prisoners, an issue that has also been identified in Epstein’s 2019 suicide as he awaited trial on sex trafficking charges. In that case, guards were sleeping and shopping online instead of checking on him every 30 minutes as required, authorities have said. The prison also never carried out a recommendation to assign him a cellmate and failed to search his cell.
The report examined deaths from 2014 through 2021 and found the numbers increasing over the last few years even as the inmate population dropped. In many cases, prison officials could not produce documents required by their own policies, the report states.
They focused on potentially preventable deaths, rather than the deaths of people receiving health care in prison.
The second-highest number of deaths documented in the report were homicides, including Bulger, who was beaten to death by fellow prisoners in 2018. Investigators found “significant shortcomings” in staffers’ emergency responses in more than half of death cases, including a lack of urgency and equipment failures.
Contraband drugs and weapons also contributed to a third of deaths, including for 70 inmates who died of drug overdoses, said Michael Horowitz, the Justice Department’s inspector general. In one case, a prisoner managed to amass more than 1,000 pills in a cell, despite multiple searches, including the day before the death, the report found.
The system has also faced major operational challenges, including widespread staffing storages and outdated camera systems, the report states. One prison went without a full-time staff physician for more than a year, and lack of clinical staffing at many others made it difficult to assess prisoners’ mental health and suicide risk, the report found.
“Today’s report identifies numerous operational and managerial deficiencies, which created unsafe conditions prior to and at the time of a number of these inmate deaths,” Horowitz said. “It is critical that the BOP address these challenges so it can operate safe and humane facilities and protect inmates in its custody and care.”
The Bureau of Prisons said “any unexpected death of an adult in custody is tragic,” and outlined steps it has taken to prevent suicides, screen for contraband and make opioid-overdose reversal drugs available in prisons. The agency said it’s also working to reduce the number of people housed alone and forestall conflicts that could lead to homicides.
An ongoing Associated Press investigation has uncovered deep, previously unreported problems within the Bureau of Prisons, including rampant sexual abuse and other staff criminal conduct, dozens of escapes, chronic violence, deaths and severe staffing shortages that have hampered responses to emergencies, including inmate assaults and suicides.
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