Roughly half of the 151 inmates in North Carolina jails who died in the past five years struggled with mental illness, substance abuse or both, state records show.
For more than a decade, North Carolina’s jails have been dealing with a sustained wave of inmates with mental illness that has increased the risk for deaths behind bars. Now, the more recent rise in opioid-addicted inmates has made the job even harder – and added to the death toll.
“Sheriffs will invariably say that ‘I as a sheriff of this county run the largest mental health hospital in the county,’ ” said Lindsay Hayes, project director of the National Center on Institutions and Alternatives and an expert on jail suicides. “And they are right. They become the repository for a lot of our counties, our state problems.”
Nationally, suicides have been the leading cause of jail deaths since 2000, according to the U.S. Bureau of Justice Statistics. In 2014, they accounted for slightly more than a third of all inmate deaths.
The federal report for 2015 is not out yet, but deaths tracked by The News & Observer for that year show a big increase in total deaths and suicides; North Carolina had its highest number of inmate deaths since 1997, according to the state Department of Health and Human Services. Of the 40 jail inmates who died in 2015 in North Carolina, 19 were suicides.
In 2016, 26 inmates died. Again, nearly half of those – 12 – were suicides.
“If half of the people who die while in jail died from a suicide, we have a serious problem that needs to be addressed immediately,” said Vicki Smith, executive director of Disability Rights NC, a nonprofit advocacy group. It also has researched North Carolina jail inmate deaths and found higher-than-average suicide rates in the past four years.
At any given time, up to 24,000 inmates are held in North Carolina’s 113 jails. They include inmates awaiting trial, some convicted of low-level misdemeanors and a few federal prisoners. The jails are supervised by elected sheriffs.
Pender County Sheriff Carson Smith Jr., who has had two suicides in his jail in the past five years, said suicide prevention is difficult. In one of those cases, DHHS found that detention officers kept the inmate on increased monitoring even after a psychologist recommended he be removed from suicide watch. He still found a way to hang himself.
“It’s very hard to stop somebody that wants to hurt themselves,” Smith said. “So we’ve had to change. We’ve had to increase our mental health screening that we do, we’ve had to make it better. We’ve had to do more training with our jail officers to be sure they know what to look for.”
Sheriffs in several other counties said they are facing the same increased risks and responding with better screening, medical treatment and supervision.
In Durham County, Sheriff Mike Andrews recently showed a reporter a section of the jail that has been vacated for the purpose of housing inmates with mental illness. He expects to have the section up and running by the end of the year, once officers receive special training.
In Wake County, two-thirds of the inmates are dealing with some form of mental illness, sheriff’s officials said. More than a quarter of all inmates are taking medication for those conditions.
Attempted suicides have risen dramatically in Wake’s two jails, from no more than one or two attempts for most of the last decade to an average of 12 in the past five years. There were 20 attempts last year, and nine in the first six months of this year, sheriff’s officials said.
Missing mental illness
Jails are ill-suited for handling the kinds of issues mentally ill or drug-addicted inmates bring. Detention officers receive little psychiatric or medical training, while the shock of confinement can intensify mental illness and make drug withdrawals especially difficult. Suicide becomes a way out.
Brandon Chase Cox had a prior suicide attempt and was abusing drugs when he was arrested for drug possession and booked into the Henderson County jail in 2014. He was incoherent upon arrival and couldn’t answer questions about his mental state until two days later.
He signed what is known as a “contract for safety,” pledging he would ask for help if he thought he needed it, and he was not placed on suicide watch. Four days later, he hanged himself. He died a day later on his 23rd birthday.
A state DHHS investigation found that Cox should have been checked four times an hour because of his past suicide attempts – and that he hadn’t been checked the minimum twice an hour when he committed suicide. The surveillance video showed he had gone unchecked for an hour and 46 minutes when he was found hanging.
Jail officials disputed the findings, contending that detention officers checked him while distributing lunch during that period.
In other cases, mental illness or drug withdrawal causes inmates to become dangerously ill, and jail staff may not pick up on it, especially if they aren’t checking regularly.
DHHS has produced tighter supervision regulations that will prevent a jail from bunching two or four rounds within several minutes in an hourlong period. Those kinds of practices technically comply with current regulations but leave a gap of time for an inmate to go unwatched. The new regulations will also require better mental health screenings. They are expected to take effect in 2018.
Vicki Smith and other advocates for those with mental illness and drug addictions say the state could do more to create a safer environment. Hayes, of the National Center on Institutions and Alternatives, has produced a 187-page manual to train jail employees to recognize high-risk inmates and provide constant supervision so they don’t have the opportunity to commit suicide.
Hayes produced the first national study on jail suicides 36 years ago, and his manual in some ways runs counter to prevailing wisdom. Some jails prevent suicidal inmates from being in contact with families, for example, fearing they may hear or see something that would push them over the edge. Hayes contends those interactions help a jail’s mental health staffers learn how an inmate is coping so they can respond appropriately.
He said in an interview one of his biggest hurdles is the belief that someone who wants to commit suicide will find a way to do it, so why spend the time and money trying to prevent it. Hayes said he has found those who follow his recommendations see a significant drop in suicides.
“If you have a sheriff that says there’s nothing you can do to prevent suicides, then he’s not going to promote suicide prevention and he’s certainly not going to implement my recommendations,” Hayes said.
Better ways to help
Many sheriffs and county commissioners have agreed to do more to reduce the numbers of mentally-ill and drug-addicted people behind bars. The national “Stepping Up” movement that seeks to reduce the number of people with mental illness in jails has won support from more than 40 North Carolina counties, including Wake, Durham, Orange and Harnett.
At a recent Stepping Up conference in Raleigh, presenters from Alamance, Pitt and Buncombe counties talked about initiatives they have developed to identify at-risk inmates and get them the help they need. Alamance Chief Deputy Sheriff Tim Britt noted his county averaged 43 inmates a day who struggled with mental illness, at a cost of $1.2 million a year. The county’s two jail facilities hold roughly 475 inmates.
He featured a former inmate with mental illness who had been caught in a cycle of repeat visits to the jail – nearly all for minor offenses – until staff helped him with housing and medicine. The former inmate has stayed out of trouble since and is now enrolled in a two-year education program.
“This is a life changed,” Britt said. “This is what Stepping Up’s all about.”
Smith, of Disability Rights NC, said the jail deaths speak to the need to create more community-based services to treat those with mental illness. State leaders promised that as part of mental health reforms started in 2001 that resulted in a reduction of beds in state mental hospitals, but they didn’t deliver.
“The answer is not to build more locked facilities, build bigger jails or larger, more bed facilities,” Smith said. “It’s actually to develop better early intervention, better behavioral health care, and work with people in a more proactive way.”
Next: After deaths, secret settlements.
How to reduce suicides
Lindsay Hayes, project director for the National Center on Institutions and Alternatives, has researched jail suicides for more than 35 years and has written a training manual for detection and prevention. Here are four of his top recommendations:
▪ Do not ignore the suicide risk when inmates deny that they will harm themselves. Their behavior, actions and history may be more telling than any pledge or promise they make.
▪ All detention officers, medical and mental health staff need meaningful suicide prevention training. It takes initial and annual training so all three groups of employees can identify suicidal inmates who are unwilling or unable to disclose they are a threat to themselves.
▪ Suicide precautions should not appear to be punitive. Inmates may be reluctant to report their suicidal thoughts or behavior if it means they are locked down, with limited access to family visits, telephone calls or showers.
▪ Develop and maintain a suicide prevention program. It should include procedures for screening for suicide risk, provide suicide-resistant housing and encourage internal and external communications that identify suicide risk. If a suicide occurs, the program should lay out the proper emergency response, reporting and notification of suicide to jail officials and the inmate’s family, and a wide-ranging review of how the suicide happened.
State regulators have started regularly investigating jail deaths, but haven’t used all the tools at their disposal. Our previous stories examine why.
Sunday: Left alone to die
Monday: No report necessary
Tuesday: Who gets punished?
Today: Housing the mentally ill
Thursday: Some courts keep secrets