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inside correctional health

Inmate Deaths

I still remember that night as if it was that day and the response we provided during
last night. All day, I had been working with the and after the event made our agency better.
director of our Community Corrections, which I cannot stress enough the importance of
fell under the authority of the sheriff’s office. A good documentation. An administrative review
participant in Community Corrections (work- includes a review of the incident and facility
release, allowed to leave for work and return procedures used. We looked at the training of
to the secure facility during off times) had been our staff in an effort to assure that all neces-
labeled a “snitch” by another group of partici- sary steps were taken. We also looked at our
pants. He was becoming increasingly paranoid response. Were the right people notified and
about his situation. were they notified in a timely manner?
Leadership and staff at the facility had taken By taking this approach (i.e., following the
every step to protect and secure the participant standards and procedures in the event of an
and were working with the courts to make the inmate death and identifying any corrective
appropriate arrangements. But it wasn’t enough action that needed to take place), we were able
for the inmate. Later that evening—before we to implement and monitor through the quality
could make contact with him—he chose to take improvement program for systemic issues and
his own life. The night just got longer. through the patient safety program for staff-
In the previous issue of American Jails (May/ related issues.
June 2021), Jail Commander Conversations We encourage you to use my experience, the
addressed suicide prevention. But what happens Jail Commander Conversations document, and
after the event has taken place? The NCCHC what we discovered during NCCHC accredi-
standard J-A-09 Procedure, “In the Event of an tation surveys to help you look at your own
Inmate Death,” addresses this question. systems. Also included on page 57 is a detailed
Recognizing that this was not an “in-cus- death review that outlines the information that
tody” death, the procedures we initiated mir- an After Action Report/Root Cause Analysis
rored what the standard required. For us, all report needs to contain.
deaths are reviewed to determine the appropri-
ateness of clinical care. Were our actions appro-
priate? Did we need to change our policies and JIM MARTIN, MPSA, CCHP
procedures? Did we need to identify issues for Vice President, Program Development
further study? jamesmartin@ncchc.org
To be sure, that was a long night, and there
were long days to follow. The event itself was AMY PANAGOPOULOS, MBA, BSN, RN
unfortunate, and I wish the young man had Vice President of Accreditation
made different choices. However, what we National Commission on Correctional Health Care
amyp@ncchc.org
learned from our response helped to strengthen
our process, and we recognized that the steps
we took were the correct ones. The accounts of

54 | JULY | AUGUST 2021 AMERICANJails