Suicide Prevention recommendations

The Suicide Prevention category includes 93 recommendations. 29 recommendations (31 percent) have been audited and completed, while the remaining 64 recommendations (69 percent) are covered by consent decrees and monitored by experts under federal court oversight.

	Not covered by Consent Decree/subject to audit by OCLEM.
	Covered by Consent Decree and subject to monitoring by federal court appointed experts.
	Completed, audited, and presented to the Board.

Recommendation	Master List Number	Status (Updates are in progress)
DOC should disband its Death Review Committee and instead utilize and attend the SCVHHS-run Death Review Committee.	217
The multidisciplinary Suicide Prevention Committee should act as the continuous quality improvement arm within DOC for suicide  prevention and should be charged with developing a corrective action plan to implement the recommendations made by Mr. Hayes, as well as monitoring implementation of any recommendations made by the Death Review Committee. DOC and SCVHHS executive leadership should attend at least the first meeting.	218
The multidisciplinary Suicide Prevention Committee should be reconstituted with a different operational mission. Instead of reviewing demographic data on suicide attempts and completed suicides, the Committee should act as the continuous quality improvement arm within the DOC for suicide prevention.	219
Intake screening for suicide risk must take place immediately upon confinement and prior to housing assignment.	220
This process may be contained within the medical screening form or as a separate form, and must include inquiry regarding: past suicidal ideation and/or attempts; current ideation, threat, plan; prior mental health treatment/hospitalization; recent significant loss (job, relationship, death of family member/close friend, etc.); history of suicidal behavior by family member/close friend; suicide risk during prior confinement; transporting officer(s) believes inmate is currently at risk.	221
The intake screening process should include procedures for referral to mental health and/or medical personnel.	222
Any inmate assigned to a special housing unit should receive a written assessment for suicide risk by mental health staff upon admission.	223
SCVHHS should revise the current suicide risk inquiry contained on the current "Medical Clearance" form embedded in the Electronic Medical Record to include the following questions about the inmates' suicide risk: 1) Have you ever attempted suicide? 2) Have you ever considered suicide? 3) Are you now or have you ever been treated for mental health or emotional problems? 4) Have you recently experienced a significant loss (relationship, death of family member/close friend, job, etc.)? 5) Has a family member/close friend ever attempted or committed suicide? 6) Do you feel there is nothing to look forward to in the immediate future (inmate expressing helplessness and/or hopelessness)? 7) Are you thinking of hurting and/or killing yourself?	224
SCVHHS officials should initiate a continuous quality assurance plan to periodically audit the intake screening process to ensure that nursing staff are asking all questions to newly admitted detainees as required.	225
DOC and SCVHHS should always initiate a mental health referral if there is documentation reflecting possible mental illness and/or suicidal behavior during an inmate's prior confinement within the DOC.	226
SCVHHS officials should develop a triage system for mental health referrals based upon acuity of behavior, including emergent, urgent, and routine.  Any inmate expressing current suicidal ideation and/or current suicidal/self-injurious behavior should result in an emergent mental health referral.	227
SCVHHS should conduct a continuous quality improvement audit to determine whether the 12 current criminal offenses that automatically result in a "charge-based mental health referral" are effective in preventing suicides.	228
Procedures that enhance communication at three levels: 1) between the sending institution/arresting-transporting officer(s) and correctional staff; 2) between and among staff (including medical and mental health personnel); and 3) between staff and the suicidal inmate.	229
Isolation should be avoided. Whenever possible, house in general population, mental health unit, or medical infirmary, located in close proximity to staff.	230
Removal of an inmate's clothing (excluding belts and shoelaces), as well as use of physical restraints (e.g. restraint chairs/boards, straitjackets, leather straps, etc.) and cancellation of routine privileges (showers, visits, telephone calls, recreation, etc.), should be avoided whenever possible, and only utilized as a last resort for periods in which the inmate  is physically engaging in self- destructive behavior.	231
SCVHHS safety smocks should be implemented only by medical and/or mental health staff and only when a clinician believes that the inmate is at high risk for suicide by hanging, not as a default or behavior management plan.	232
SCVHHS should develop suicide prevention policies to address procedures for deciding which possessions and privileges are provided to inmates on suicide precautions.	233
Two levels of supervision are generally recommended for suicidal inmates- close observation  and constant observation. Close observation is reserved for the inmate who is not actively suicidal, but expresses suicidal ideation  or does not threaten suicide, but demonstrates other concerning behavior (through actions, current circumstances, or recent history) indicating the potential for self-injury, should be placed under close observation.  This inmate should be observed by staff at staggered intervals not to exceed every 10 minutes. Constant Observation is reserved for the inmate who is actively suicidal, either by threatening or engaging in self-injury. This inmate should be observed by a staff member on a continuous, uninterrupted basis.  Other supervision aids (e.g., closed circuit television, inmate companions/watchers, etc.) can be utilized as a supplement to, but never as a substitute for, these observation levels. Inmates on suicide precautions should be reassessed on a daily basis.	234
SCCSO and SCHHS suicide prevention policies should include two levels of observation (close observation and constant observation) that describe with specificity the behavior warranting each level of observation.	235
SCVHHS should eliminate the minimum and maximum length of stay on suicide precautions for inmates identified as suicidal and instead use clinical judgement on a case-by-case basis to determine the length of stay.	236
SCVHHS should revise any suicide prevention policy to permit both custody and medical staff to initiate suicide precautions and require that only mental health staff can discontinue suicide precautions after a comprehensive suicide risk assessment.	237
SCVHHS’s draft  Suicide Risk Assessment form should be finalized and implemented as soon as possible. The current draft should be revised to include a disposition section (e.g., initiate, continue, or discharge suicide precautions; specified level of observation; etc.), as well as a treatment or safety plan section that requires the clinician to specify strategies to reduce future suicidal ideation.	238
All SCVHHS clinicians (including psychiatrists and other qualified mental health professionals) should complete the Suicide Risk Assessment form whenever an inmate is identified and referred for possible suicidal behavior. The Suicide Risk Assessment form should be utilized at least twice, i.e., for initiation of suicide precautions, as well as justification for discharging the inmate from suicide precautions.	239
The Suicide Risk Assessment form should be completed in a private setting and not cell-side unless the inmate-patient refuses a private interview. Refusal of a private interview should be documented in the electronic medical record (EMR).	240
SCVHHS mental health clinicians should develop treatment plans for inmates discharged from suicide precautions. Those plans should describe signs, symptoms, and the circumstances in which the risk for suicide is likely to recur; how recurrence of suicidal thoughts can be avoided; and actions the patient or staff can take if suicidal thoughts occur.	241
SCVHHS should ensure that all inmates discharged from suicide precautions remain on mental health caseloads and receive regularly scheduled follow-up assessments by mental health staff until their release from custody, in order to safeguard the continuity of care for suicidal inmates.	242
A facility’s policy regarding intervention should be threefold: 1) all staff who come into contact with inmates should be trained in standard first aid and cardiopulmonary resuscitation (CPR); 2) any staff member who discovers an inmate attempting suicide should immediately respond, survey the scene to ensure the emergency is genuine, alert other staff to call for medical personnel, and begin standard first aid and/or CPR; and 3) staff should never presume that the inmate is dead, but rather initiate and continue appropriate life-saving measures until relieved by arriving medical personnel.	244
In addition, all housing units should contain a first aid kit, pocket mask or mouth shield, Ambu bag, and rescue tool (to quickly cut through fibrous material). All staff should be trained in the use of the emergency equipment. Finally, in an effort to ensure an efficient emergency response to suicide attempts, “mock drills” should be incorporated into both initial and refresher training for all staff.	245
DOC should ensure that the compliance rate of CPR/AED training for custody personnel (excluding those who might be out on disability or other leave) be maintained at a minimum of 90 percent.	246
Every completed suicide, as well as serious suicide attempt (i.e., requiring hospitalization), should be examined by a morbidity- mortality review. (If resources permit, clinical review through a psychological autopsy is also recommended.)	247
The review, separate and apart from other formal investigations that may be required to determine the cause of death, should include: 1) review of the circumstances surrounding the incident; 2) review of procedures relevant to the incident; 3) review of all relevant training received by involved staff; 4) review of pertinent medical and mental health services/reports involving the victim; 5) review of any possible precipitating factors that may have caused the victim to commit suicide or suffer a serious suicide attempt; and 6) recommendations, if any, for changes in policy, training, physical plant, medical or mental health services, and operational procedures.	248
Further, all staff involved in the incident should be offered critical incident stress debriefing.	249
SCVHHS should revise an existing policy or create a new policy that sets forth appropriate procedures for conducting the Death Review Committee.	250
DOC representatives to the Death Review Committee should become active participants and partners on the SCVHHS-run Death Review Committee.	251
All SCVHHS mental health personnel (including psychiatrists) should receive additional training on: 1) how to complete the Suicide Risk Assessment form, which should include examples of adequate and inadequate assessments; and 2) how to complete a reasonable treatment plan that contains specific strategies for reducing future suicidal ideation, which should include examples of adequate and inadequate treatment plans.	252
Cell doors- large vision panels that are never covered	253
Cell doors-interiors devoid of handles/knobs	254
Cell doors- Food pass via recessed door pulls that can close and lock	255
Cell doors- interior hinges bevel down.	256
Cell doors- door frame rounded with smooth top edges.	257
Cell doors- grouted with minimal exposed edges.	258
Cell doors- paneling or security screening installed inside cell doors with steel bars.	259
Cell doors- Solid cell fronts modified with vision panel or small mesh.	260
Vents, ducts, grills, lights- protrusion free and covered with screening, tamper proof.	261
Drains- holes 1/8 in wide and no more than 3/16 in wide or 16 mesh per square inch.	262
Telephone Cords- no wall mounted cords placed inside cells.	263
Clothing hooks- none.	264
Toilet-sink- concealed plumbing with outside control valve.	265
Toilet-sink- no anti-squite slit, toothbrush holder, toilet paper rod, towel bar.	266
Beds- heavy molded plastic or concrete slab with rounded corners.	267
Bunks- bolted flush to the wall.	268
Bunks- holes covered.	269
Bunks- ladders removed.	270
Bunks- covered underneath.	271
Electricity- turned off from wall outlets outside of cell.	272
Lighting- Ample light for reading.	273
Lighting- Low wattage night light bulbs.	274
Infrared filter over the ceiling lights.	275
CCTV monitoring- identifies a suicide attempt in progress.	276
CCTV monitoring- Camera should be enclosed in a tamper-proof box and does not contain anchoring points	277
CCTV monitoring- Cells with monitors should be painted in pastel.	278
CCTV monitoring- Cameras should have clear view of all four corners and day and night capabilities.	279
Smoke detectors- mounted flush in the ceiling.	280
Smoke detectors- audible alarm at control desk.	281
Smoke detectors- protective coverings high enough to be outside the reach of an inmate.	282
Smoke detectors- far enough away from the toilet to not be used as a ladder.	283
Smoke detectors- 10 ft ceiling height.	284
Install v- mesh covering not large enough to thread a noose through.	285
Water sprinklers- head should not be exposed.	286
Audio monitoring intercom- turned up high to hear calls for distress or movement.	287
Location of suicide precaution cells- as close to the control desk as possible.	288
Modesty walls/ shields- triangular, rounded or sloping tops to prevent anchoring.	289
Modesty walls/ shields- both head and feet visible.	290
Desks, benches, tables, stools or pull- out seats- extend bed slab for use as a seat.	291
Desks, benches, tables, stools or pull- out seats-cylinder-shaped concrete seat anchored to the floor with rounded edges.	292
Desks, benches, tables, stools or pull- out seats- triangular corner desktop anchored to the two walls.	293
Desks, benches, tables, stools or pull- out seats- rectangular desk top with triangular end plates anchored to the wall.	294
Desks, benches, tables, stools or pull- out seats- towel racks should be removed from any desk area.	295
Shelf tops and exposed hinges- solid, triangular end-plates.	296
Security windows- outside view to identify day via sunlight.	297
Security windows- covered with Lexan paneling to prevent access to bars.	298
Security windows- if screening or grating is used, cover holes.	299
DOC Officials should look at options for better ensuring reasonable sound privacy at the booking counter when multiple nurses are conducting intake screening.	300
SCVHHS mental health staff should conduct screening and/or crisis assessments in an area the provides reasonable privacy and confidentiality.	301
Inmates should be housed in suicide- resistant, protrusion free cells.	302
SXXSO officials should designate specific cells within DOC that will be utilized to house suicidal inmates, and then embark upon an inspection program to ensure that inmates on suicide precautions are housed in "suicide-resistant" cells.  Specific recommendations regarding the removal of obvious protrusions in cells can be found in the "Checklist for the Suicide-Resistant" Design of Correctional Facilities."	303
All correctional, medical, and mental health staff should receive 8 hours of initial suicide prevention training, followed by 2 hours of annual training.	304
At a minimum training should include avoiding negative attitudes to suicide prevention, inmate suicide research, why correctional environments are conducive to suicidal behavior, potential predisposing factors to suicide, high- risk suicide periods, warning signs and symptoms, identifying suicidal inmates despite the denial of risk, components of the agency's suicide prevention policy, and liability issues associated with inmate suicide.	305
DOC and SCVHHS should only utilize classroom-instructed suicide prevention training.	306
DOC and SCVHHS should collaborate on the development of a new 4 to 8 hr pre-service suicide prevention curriculum for new employees.	307
DOC and SCVHHS should collaborate on the development of a two-hour annual suicide prevention curriculum for all custody, medical and mental health staff.	308
SCVHHS mental health personnel (including psychiatrists) should receive additional training on comprehensive suicide risk assessments and how to develop a reasonable treatment plan that contains specific strategies for reducing future suicidal ideation.	309
Review best practices for suicide prevention for custodial facilities.	396