Ventura County Grand Jury • 2010-2011

Inmate Processing and Suicide Prevention in the Ventura County Jail

Published: May 31, 2011 49 pages
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Findings and Recommendations 37 findings

F01
The Sheriff is mandated to establish institutional processes that meet legal standards. Attempting to avoid a statistically rare event, like a suicide, is a unique management challenge. It takes an institutional focus on this kind of issue to insure that despite the conflicting demands and budget priorities of day-to-day events, this issue is always part of the management process. Other than the Sheriff, there is no one individual formally responsible for suicide prevention in the County Jail. (FA-01 through FA-04)
No recommendations for this finding
F02
The majority of those booked into County Jail return to private life in the community and some are sent to a state prison. Some individuals are booked into the County Jail and released on a regular basis. A statistically small number die in County Jail custody. Of the 28,045 bookings in 2010, three inmates have died. (FA-03 and FA-04, FA-06 through FA-11)
No recommendations for this finding
F03
The Sheriff has instituted a set of processes to screen, monitor, respond, and evaluate inmate suicides. After review of the literature, the Grand Jury has determined that some of these processes are considered to be best practices (e.g., the 72-hour reception housing and the multi-stage screening). These processes involve not just the detention staff, but also the Major Crimes staff and contracted medical staff. The Sheriff has instituted a project to modify the County Jail based on lessons learned from past suicides. (FA-05, FA-14 through FA-16)
No recommendations for this finding
F04
Institutionally, dealing with potentially suicidal inmates is a challenging problem. Collecting information from those inmates about suicidal factors is sometimes difficult. Some inmates withhold information from custody staff even when it is in their best interest to provide that information. Some inmates withhold information when it is not in the best interest of their cellmate. Sometimes families are not forthcoming with pertinent information until after the event. Some inmates make non-serious attempts at suicide, therefore compounding the suicide prevention problem. Some aspects of suicidal tendencies are associated with mental illness. (FA-13, FA-24 and FA-25)
No recommendations for this finding
F05
When compared with nationwide data collected from the Justice Department, the County Jail ranks in the top 12 percent in experiencing inmate deaths for seven of the last eleven years. Its eleven-year suicide rate is less than the smallest jails nationally and greater than most of the largest jails in California. Both suicide and mortality rates in the County Jail have risen over the three-year period 2008 through 2010. There are many factors correlated with 10 Inmate Processing and Suicide Prevention suicides in a jail environment. When addressing a specific institution, the analysis of the two suicide events in 2010 does not provide enough data to make a credible evaluation of patterns, but does lead to an understanding of special factors, e.g., cell configuration. (FA-04, FA-06 through FA-12, and FA-36)
No recommendations for this finding
F06
The VCSD Policies and Procedures track all of the elements of a suicide prevention program identified by the National Commission on Correctional Health Care. There is not a single “Plan” for the VCSD, but a program does exist. The suicide prevention program is not represented in a single document, but it meets Title 15 criteria. What is significant is that all of the written policies and procedures exist in a coherent framework and contain standard practices that are not only followed to the letter, but are followed with commitment as well. For example, the immediate institutional responses to the suicides of inmates A and B were timely and appropriate. The teamwork that was demonstrated in the institutional responses to these two suicides indicates the dedication that exists within the detention staff. (FA-14 through FA-19, FA-22 through FA-26, FA-28, and FA-30 through FA-34)
No recommendations for this finding
F07
Despite the thoroughness and dedication of the VCSD Major Crimes investigators, the fact that the VCSD is investigating deaths in its own jail can be perceived as a lack of transparency. This can lead to a false perception as to the integrity of the investigative process and findings. (FA-23 and FA-28)
No recommendations for this finding
F08
The participation of the VCSD, the Jail Work Group of the Ventura County Mental Health Board, and the VCBHD with regard to inmate release, has demonstrated an openness that allows for effective communications across the community. This kind of relationship can be considered a best practice. (FA-29)
No recommendations for this finding
F09
There is a spectrum of personnel available to observe the potential suicidal inclinations of inmates. These include individual deputies, chaplains, and psychiatrists from the CFMG, religious volunteers, teachers, work supervisors, and maintenance personnel. The amount of training regarding suicidal issues in this spectrum is varied. (FA-30, FA-33, and FA-37)
No recommendations for this finding
F10
Psychological Autopsies have not been an explicit element in the VCSD suicide assessment process. There are two institutional resources available to the VCSD with the technical capability to support custody staff in performing Psychological Autopsies: the CFMG and the VCBHD. The CFMG is a contractor to the VCSD with a clinical perspective; the VCBHD is an independent organization within the County with a community-based perspective. (FA-35) (Att-04)
Related Recommendations (2)
R03
The Sheriff should solicit the Ventura County Health Care Agency for VCBHD’s participation with the VCSD legal unit in the analysis of suicides in order to provide an independent perspective. (FI-06, FI- 08, and FI-10)
R10
The Sheriff should consider requesting the VCBHD and the CFMG to support the performance of Psychological Autopsies on inmates A and B. (FI-03 and FI-10)
F11
The stoic culture of custody staff and inmates is an inhibiting factor in their requesting counseling services. This can preclude staff and Inmate Processing and Suicide Prevention 11 inmates from requesting counseling services even if those services could be beneficial. (FA-29) Recommendations
No recommendations for this finding
F12
At least 80% of suicides in custody occurred in the inmate’s cell; time of day was not a factor. [Ref-06]
No recommendations for this finding
F13
A definitive cause-effect relationship between risk factors and suicidal death cannot be established. Some inmates attempt suicide with no intention of ever completing the act, while others persist, using more lethal methods until successful. [Ref-07]
No recommendations for this finding
F14
The VCSD systematic process for receiving, housing, and monitoring inmates is as follows: A Transporting Officer introduces the inmate to the facility. The booking process begins with completion of the initial Intake Health Screening Form. (Att-01) The inmate is then classified as to type of housing. Based on the results of this initial screening form, an immediate medical review may be undertaken; otherwise, the screening form is reviewed later in the booking process by medical staff. The classified inmate is then placed in a 72-hour Reception Housing Area for incoming inmates. The inmate is closely monitored prior to assignment to long-term housing. Before leaving Reception Housing and being assigned to long-term housing, the inmate is interviewed by medical staff and a Reception Housing Clearance, Reception Housing Bypass Form is completed. (Att-02) After being assigned to a cell and monitored hourly, any anomalies in the inmate’s situation may cause reassignment to a cell which is more intensively monitored. Depending on the type of cell to which the inmate is assigned, the inmate is monitored every 15 minutes (Safety/Suicide Watch cells and Sobering cells), every 30 minutes (Medical Housing and Suicide Precaution cells), or every hour (all other cells). Logs of monitoring activities are recorded electronically for every cell monitored hourly. Logs are recorded manually for the Safety, Sobering, and Medical housing cells. If an inmate emergency occurs, a critical response protocol is executed. Deputies secure the area and implement emergency procedures. Jail medical personnel respond with a higher level of care. When necessary, Emergency Medical Technicians assume medical responsibility and transport the inmate to the hospital. If a death ensues, the Medical Examiner performs an examination and issues a report. The VCSD Major Crimes unit investigates and issues an investigative report. If it is determined to be a suicide, these reports are reviewed by the Legal Sergeant on the staff of the head of detentions. Based on this review, the Legal Sergeant, in conjunction with other detention staff members, may recommend changes to detention policy, training, or facilities. [Ref-08] Inmate Processing and Suicide Prevention 5
No recommendations for this finding
F15
Two parts of the screening process are conducted prior to the assignment of an inmate to long-term housing. The first screening is completed prior to the 72-hour Reception Housing process. This is done by booking deputies with support, as required, from the California Forensic Medical Group (CFMG) medical personnel. The completion of the first form may trigger an immediate interview with CFMG medical personnel. Otherwise, the form is reviewed by CFMG prior to the inmate leaving the booking floor. (Att-01) The second screening is completed and documented by CFMG after the 72-hour Reception Housing interval. These two forms capture the mental and physical health state of the inmate. While the Ventura County Justice Information System (VCJIS) is able to easily keep track of institutional data on inmates who have had multiple bookings, these two paper forms used in the screening process are not maintained electronically. (Att-02) A briefing paper developed by the California Corrections Standards Authority includes a screening form with data elements that are not included in the Ventura County forms. [Ref-09] (Att-03)
No recommendations for this finding
F16
The sources of information about inmates are the inmates themselves, transportation officers, intake personnel, custodial personnel, fellow inmates, and medical staff. If the inmate is a client of the Ventura County Behavioral Health Department (VCBHD), VCBHD medication records are available. If the inmate was previously incarcerated, criminal history data is also available in VCJIS.
No recommendations for this finding
F17
Besides uniformed VCSD personnel, there are other categories of people who can have direct access to inmates. They include ministers, teachers, adult literacy volunteers, and civilian supervisors of the kitchen and print shop, etc.
No recommendations for this finding
F18
Inmate communications with family, friends, and the outside world are mail, telephone calls, and personal visits. Visitors enter a lobby area where there are posted regulations.
No recommendations for this finding
F19
Staff supporting the County Jail for medical and psychiatric services is contracted through CFMG. This group has been under contract with Ventura County since 1987. [Ref-10]
No recommendations for this finding
F20
A subsidiary of the California Medical Association, The Institute for Medical Quality (IMQ), has awarded the Ventura County Adult Correctional Facilities accreditation for demonstrating 100% compliance with the IMQ applicable Essential Standards. The accreditation period is September 2010 to September 2012. [Ref-11]
No recommendations for this finding
F21
The suicide monitoring and response process is implicit in many aspects of County Jail operation, including management, Legal 6 Inmate Processing and Suicide Prevention Sergeant, custody staff, investigators, medical staff, and intake screening staff.
No recommendations for this finding
F22
The County has a process improvement approach for organizational evaluation and review of its departments. The Sheriff has embraced this approach to organizational change. A part of this management approach is to identify and emulate best practices from any source. The Sheriff has reduced overhead in his administration. For example, Detention Services and Major Crimes now report to the same Assistant Sheriff.
No recommendations for this finding
F23
In 2010, one inmate died of natural causes; two inmates, A and B, were suicides. Inmates A and B had prior incarcerations. Inmate B had been incarcerated on a frequent basis during the prior six years. The ages of the three were between 48 and 52. In the case of the suicides of inmates A and B, custody personnel responded quickly. Deputies and attending nurses performed emergency procedures until Emergency Medical Technicians arrived in a timely manner and transported the inmates to the hospital.
No recommendations for this finding
F24
Inmate A left reception housing and was interviewed by a nurse three days after booking. Inmate A was transferred from the MJ to the TRJ eight days after booking. Inmate A was found hanged in his cell 104 days after booking. An after-death investigation identified that former cellmates stated they had observed two prior suicide attempts. The first attempt was reportedly one day after booking; the second was 96 days after booking. Both attempts were unknown to the custody staff prior to the suicide investigation. The first cellmate claimed to have had contact with an unsworn employee at the MJ about this incident. This contact was not substantiated. The second attempt at the TRJ was not communicated to VCSD personnel by the cellmate before the successful suicide.
No recommendations for this finding
F25
Inmate B was interviewed by a nurse at the end of reception housing. He was transferred from the MJ to the TRJ four days after booking. Inmate B was found hanged in his cell eleven days after booking. Subsequent investigation indicated that some family members were aware that the inmate had a bipolar disorder, was under psychiatric care, and had exhibited suicidal behavior. This information was not communicated to custody personnel.
No recommendations for this finding
F26
Based on the analysis of prior suicides, various modifications to cells were initiated to mitigate suicide. These included rounding of bunk railings to prevent attachment of a rope or sheet and installing clothing hooks that would not support the weight of an inmate without giving way. These modifications were observed in the MJ but, based on review of the Investigative Reports and Grand Jury visits, the bunk alterations were not yet completed in the cells of inmates A or B at the TRJ. Inmate Processing and Suicide Prevention 7
No recommendations for this finding
F27
The VCSD investigates all deaths in the County Jail. The Medical Examiner determines the cause of death and notifies the family of the decedent. If a death is determined to be a homicide, the District Attorney is presented with the investigative results. Similarly, the District Attorney is presented with the results of all investigations of officer involved shootings. In the case of suicides, the District Attorney is not presented with investigative results.
No recommendations for this finding
F28
The VCBHD currently participates with the Sheriff in a number of ways: A VCBHD employee works in the County Jail to facilitate discharge planning of inmates and works jointly with custody personnel in support of the Jail Workgroup of the Ventura County Mental Health Board (VCMHB). The VCBHD screens inmate lists in order to identify those inmates who are already being served by the VCBHD. Some medication record formats have been standardized between the County Jail and the VCBHD to allow smooth access to medication records. The VCBHD does not participate in the evaluation of suicides and attempted suicides within the County Jail. The VCBHD supports the quarterly Quality Assurance Reviews of the CFMG.
No recommendations for this finding
F29
Dealing directly with suicides is stressful and challenging. Employees of the VCSD have the Employee Assistance Program (EAP) that provides stress counseling to members of the custody staff. Supervisors can encourage employees to avail themselves of this service. Custody personnel have acknowledged the stressful impact of suicide incidents and have, in some cases, declined suggested counseling. Chaplains and CFMG medical personnel provide a similar counseling role for inmates when requested. In the particular case of the suicide of inmate B, CFMG provided an unrequested psychiatric intervention to a cellmate who demonstrated a severe emotional reaction.
Related Recommendations (1)
R07
The Sheriff should consider developing a supplemental Critical Incident Stress Debriefing protocol for staff and inmates who are involved with suicides. (FI-06 and FI-29)
F30
The uniformed personnel in the County Jail are composed of Sheriff Deputies and Sheriff Service Technicians (SSTs). Deputies undergo a six-month VCSD Academy training program. County Jail SSTs undergo a 176-hour training program developed by the California Corrections Standards Authority. Both deputies and SSTs also attend an 80-hour Standards and Training for Corrections Course (STC). All uniformed custody personnel are trained and annually tested in twenty-four knowledge domains associated with specific custody situations.
No recommendations for this finding
F31
Of the 80 hours of STC training, one hour is devoted to “Indicators of Suicide (In a Jail Setting).” [Ref-12] 8 Inmate Processing and Suicide Prevention
No recommendations for this finding
F32
Counseling by chaplains is a key component in any suicide prevention program. Chaplains in the County Jail undergo specialized training developed by the International Conference of Police Chaplains (ICPC). Suicide prevention is part of the training. Two chaplains and a Catholic Services Representative coordinate the efforts of clerical volunteers from over 50 churches to provide religious support to the inmates. All three of these coordinators have had suicide prevention training.
No recommendations for this finding
F33
There are approximately 350 volunteers and non-uniformed staff who provide a number of services to the inmates. These activities include vocational, adult literacy, religious, educational, family, and discharge planning services.
No recommendations for this finding
F34
The National Institute of Corrections Library identifies a thirty-two hour instructional program on suicide prevention. [Ref-13]
No recommendations for this finding
F35
In some organizations experiencing multiple suicides, the process of reviewing suicide deaths has involved the use of a procedure designated as a “Psychological Autopsy.” For example, Psychological Autopsy is considered by the Department of the Army as a key element in the assessment of suicides in its Suicide Prevention Program. [Ref-15] (Att-03)
No recommendations for this finding
F36
Using the metrics developed by the U.S. Department of Justice and the average daily population and mortality data from the VCSD for the County Jail, over the eleven-year period from 2000 through 2010, the average annual suicide rate was 59 per 100,000 inmates and the average annual mortality rate was 170 per 100,000 inmates. When calculated over the eight-year period from 2000 through 2007, the annual suicide rate was 48 per 100,000 and the average annual mortality rate was 138 per 100,000. Over the three-year period 2008 through 2010, the suicide rate was 83 per 100,000 and the average annual mortality rate was 209 per 100,000.
No recommendations for this finding
F37
A recent report from the National Institute of Corrections has indicated the following: a) Inmate suicide is no longer centralized in the first 24 hours of confinement and can occur at any time within the inmate’s confinement; b) All correctional, medical, and health personnel, as well as any staff who have regular contact with the inmates, should receive eight hours of initial suicide-prevention training and two hours of refresher training each year; c) The majority of inmates who committed suicide attended (or were scheduled to attend) a court hearing within two days of when they committed suicide; d) Every completed suicide as well as attempts that require hospitalization should be examined through a morbidity- mortality review process, ideally, coordinated by an outside agency. Inmate Processing and Suicide Prevention 9 A psychological autopsy is recommended as part of this process. [Ref-16] Findings
No recommendations for this finding

Commendations 3

No Responses Found 3

Government entities assigned to respond to this report. No response documents have been linked in our database.

County of Ventura Agency
Ventura County District Attorney Elected County Office
Ventura County Sheriff Elected County Office