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 over the 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.
The Justice Department watchdog report, triggered in part by those high-profile deaths, examined 344 deaths over the course of eight years. Investigators found policy violations and operational failures in many of those cases.
Among the 187 suicide cases, they found inmates whose mental health assessments appeared wrong and others who were housed in a single cell, which increases the risk of suicide.
Staff also failed to do sufficient checks of prisoners in one-third of the suicide cases, something investigators also found contributed to Epstein’s 2019 suicide as he awaited trial on sex trafficking charges. In that case, authorities have said guards were sleeping and shopping online instead of checking on him every 30 minutes as required. The prison also failed to search his cell and never carried out a recommendation to assign him a cellmate, factors that were also echoed in other cases.
The report examined deaths from 2014 through 2021 and found the numbers increasing in recent years even as the inmate population dropped. In many cases, prison officials could not produce documents required by their own policies, the report states.
Investigators focused on potentially preventable deaths, rather than people who died while 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, a hesitancy to use the opioid-overdose drug naloxone and equipment problems. In one instance, a prisoner died after a health care staffer accidentally turned off a defibrillator instead of administering an electric charge.
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 is facing major operational challenges, including outdated camera systems and widespread staffing storages that make overworked employees into “walking zombies,” some of whom are required to work 16-hour-days, 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.