Other Matters: The Bristol County Sheriff’s Office Took Measures To Improve Its Mental Health Assessments of Inmates and To Prevent Death by Suicide at Its Facility.

During the audit period, there were three deaths at Bristol County Sheriff’s Office (BCSO’s) facilities, two of which BCSO reported as suicide by hanging. We determined that BCSO followed its policies and procedures when handling those deaths in custody.

Overview

During the audit period, there were three deaths at Bristol County Sheriff’s Office (BCSO’s) facilities, two of which BCSO reported as suicide by hanging. We determined that BCSO followed its policies and procedures when handling those deaths in custody. Its procedures, as outlined in BCSO’s Policy 12.02.00 (Terminal Illness, Advance Directives and Death) include the following:

• notification of the next of kin;
• notification to internal medical and administrative employees;
• necessary actions¹⁷ taken by appropriate staff members when the body was discovered;
• investigation of the cause(s) of the death;
• documentation of the procedures that BCSO employees took; and
• evaluation of the incident by appropriate, designated BCSO employees.

Based on our review of the morbidity and mortality reports for the deaths that occurred during our audit period, we determined that BCSO conducted mental health assessments on these inmates before their deaths and did not find any immediate mental health concerns. Nevertheless, two additional deaths by suicide happened after the audit period, between July 1, 2022 and June 30, 2023. Therefore, we believe that BCSO needed to improve its mental health assessment process. We determined that BCSO has taken certain steps toward this, as described below.

During our audit, BCSO’s administration transitioned to a new Sheriff. Soon after the new Sheriff took office, BCSO hired a consultant who specializes in suicide prevention within jails, prisons, and juvenile facilities to review and assess BCSO’s practices related to this area. The following are some examples of the recommendations that the consultant made:

1. Training: BCSO should offer annual training for all BCSO employees and Correctional Psychiatric Services contractors, including suicide prevention and how to conduct a mental health assessment.
2. Intake Medical Screenings and Initial Health Assessments: BCSO should enhance the intake medical screening and the initial health assessment by ensuring confidentiality and adding the following questions (as stated in the consultant’s Report on Jail Suicide Prevention Practices within the Bristol County Sheriff’s Office) to the questionnaire that inmates complete during their intake medical screening:

• Have you ever considered suicide?
• Have you recently experienced a significant loss (relationship, death of family member/close friend, job, etc.)?
• Has a family member/close friend ever attempted or committed suicide?
• Do you feel there is nothing to look forward to in the immediate future (inmate expressing helplessness and/or hopelessness)? . . .
• Do you have any current thoughts or plans to hurt yourself?

3. Housing: According to the consultant’s Report on Jail Suicide Prevention Practices within the Bristol County Sheriff’s Office, BCSO should ensure that all housing assignments are suicide-resistant by replacing any metal bunk bed frame with “either heavy molded plastic or solid concrete slab with rounded edges.”

The actions taken by BCSO thus far—including hiring a consultant to review its policies and procedures related to suicide prevention and implementing the consultant’s recommendations—may have a positive outcome in reducing the reoccurrence of death by suicide at its facility. We encourage BCSO to continue improving the care it provides to its inmates.

17.   Please see “Inmate Deaths” in the Overview section of this report.

Date published:	February 2, 2024