BOP Program Statement 5332.01 § 16

In the event of an obvious or suspected (e.g., potential overdose) inmate death by suicide, the

Warden will make appropriate notifications to the RD and Central Office Executive Staff. The

Chief Psychologist will notify the NSPC and the Regional Psychology Administrator.

The need to perform life-saving measures takes top priority and should not be delayed or

curtailed based on a presumption of death (except in those circumstances outlined in Program

Statement Patient Care) or concerns about crime scene preservation.

In accordance with Program Statement Crime Scene Management and Evidence Control,

following the emergency response, the suicide scene will be treated in a manner consistent with

an inmate death investigation. All measures to preserve and document the evidence needed to

support subsequent inquiries will be undertaken and recorded. Institution staff, particularly the

Evidence Recovery Team, will handle the site with the same level of protection as any potential

crime scene in which a death has occurred. When there is an inmate death or serious incident that

may lead to death or incapacitation, the incident will be recorded in TRUSCOPE. Once all

evidence and property have been secured, examined, retained, and written Federal Bureau of

Investigation (FBI) declination has been obtained (if applicable), the scene may be released.

In the event of an inmate death by suicide, no clinical documentation from Psychology Services

should be added, altered, or completed after the death.

a. Psychological Reconstruction of an Inmate Suicide. The professional purpose of a

Psychological Reconstruction is to aid in the understanding and prevention of suicide. The

specific goals of each Psychological Reconstruction are to determine, if possible, why an inmate

decided to end their own life, and what can be learned from the death that could help to

strengthen the institution’s local suicide prevention program and the Bureau’s national suicide

prevention program. Psychological Reconstruction reports do not focus solely on policy

violations but also on the identification and recommendation of new practices that strengthen the

Bureau’s suicide prevention program.

Ordinarily, the RSD AD, will authorize a Psychological Reconstruction of an inmate suicide to

be completed under the direction of the NSPC or another psychologist from the PSB. Central

Office psychologists who have previously been involved in treating or consulting about the

inmate ordinarily do not participate in the reconstruction. A Psychological Reconstruction team

may consist of additional staff including, but not limited to, representatives from the Office of

General Counsel (OGC), the Health Services Division (HSD), the Correctional Programs

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Division (CPD), and regional staff as approved by the RD. Participants from the field may be

considered on a case-by-case basis but must be at the department head level or above. If a death

by suicide occurs at an RRC, a suicide reconstruction may be conducted depending on the

specific concerns of the agency.

Wellness of staff and inmates following a death by suicide is of the utmost importance. One task

of the reconstruction team is to ensure wellness of both groups is addressed during the site visit.

At the conclusion of the reconstruction, a report is prepared that addresses all of the areas

outlined in the Guide for the Psychological Reconstruction of an Inmate Suicide. This guide can

be found on the PSB page of the Bureau’s intranet site. The report will be reviewed by OGC,

HSD, and CPD; feedback will be considered by the NSPC and/or the psychologist who authored

the report. Other disciplines may be consulted at the discretion of the NSPC based on the unique

features of a particular case.

The RSD AD will review and approve the final report and disseminate copies to the Health

Services Division AD; the Correctional Programs Division AD; the Program Review Division

AD; the RD responsible for the institution where the suicide occurred; the Warden at the

institution where the suicide occurred; and other Wardens as appropriate (e.g., if the inmate was

recently transferred). The final report will ordinarily be routed within 120 days of the completion

of the site visit.

If the suicide occurred at an RRC, and a reconstruction is conducted, the report is disseminated

to the RRMB Administrator.

b. Psychological Reconstruction Follow-Up Procedures. Within 60 days of receiving a

Psychological Reconstruction report, the Warden prepares an Institution Response. Wardens are

encouraged to consult with the Regional Psychology Administrator in preparing the institution’s

response. The response will include a comprehensive corrective action plan and is routed by the

Warden through the RD to the RSD AD. A copy of the memo format for this corrective action

plan can be found on the PSB page of the Bureau’s intranet site.

If the suicide occurred at an RRC, and reconstruction is conducted, the RRM overseeing that

RRC completes the follow-up procedures outlined in this Section of the program statement.

Upon receipt by the RSD AD, the Institution Response will be forwarded to the NSPC and/or the

author of the Psychological Reconstruction report for review. If all corrective action plans appear

to be appropriate, the RSD AD prepares a response for the Warden through the RD indicating the

conclusion of the psychological reconstruction process. If there are questions or concerns about

the corrective action plan, a detailed response is prepared and routed from the RSD AD through

the RD to the Warden requesting additional information or clarification. Should that occur, a

follow-up Institution Response is submitted to the RSD AD within 30 days.

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c. Reporting Frequent Psychological Reconstruction Findings. The NSPC will track trends

in deaths by suicide, frequent recommendations, and best practices to prevent suicide. This

information will be compiled into a report and distributed broadly (e.g., ADs, RDs, Wardens,

Psychology Services staff) on a quarterly basis.

d. Risk Reduction Reviews. Institutions identified as having high rates of inmate death by

suicide will receive a Risk Reduction Review from a multidisciplinary team approved by the

RSD Assistant Director. At a minimum, this team will include two representatives from PSB, a

representative from HSD, a representative from the Correctional Services Branch, and

representatives from the regional office (as approved by the RD). Risk Reduction Reviews will

occur at institutions that experience two or more inmate deaths by suicide in two calendar years.

This also applies to complexes. Ordinarily, at a complex, each institution will be treated as an

individual entity for the purposes of a Risk Reduction Review. If a complex has two or more

deaths, and the deaths occurred at separate institutions, no Risk Reduction Review will be

completed. If there are two or more deaths at a single institution within the complex, a Risk

Reduction Review will be completed. Other circumstances may warrant a review outside of these

criteria at the discretion of the RSD AD. The review will examine adherence to reconstruction

recommendations, physical safety, communication and interaction styles, provision and fidelity

of evidence based mental health treatment, perceptions of the use of discipline and restrictive

housing, the reporting and referring culture of the facility (e.g., is it caring), and facility staffing.

A report will be written to disseminate findings and make additional recommendations.

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REFERENCES

Program Statements

Food Service Manual

Female Offender Manual

Management of Inmates with Disabilities

Visiting Regulations

Special Housing Units

Intake Screening

Treatment and Care of Inmates with Mental Illness

Psychology Services Manual

Crime Scene Management and Evidence Control

Use of Force, Application of Restraints, and Firearms

Patient Care

Psychiatric Services

Bureau Forms Prescribed by 5332.01

BP-A1182, Self-Directed Violence High Lethality Review

BP-A1183, Suicide Watch Property Authorization

Other Bureau Forms

BP-A0519, Psychology Services Inmate Questionnaire

Federal Regulations

28 CFR 552.40–42.

ACA Standards

Performance-Based Standards and Expected Practices for Adult Correctional Institutions (5th

Edition): 5-ACI-1D-12, 5-ACI-1D-13, 5-ACI-4B-28(M), 5-ACI-6A-31(M), 5-ACI-6A-32(M), 5-

ACI-6A-35(M), 5-ACI-6B-08(M), 5-ACI-6B-12, 5-ACI-6B-13, 5-ACI-6D-02(M)

Performance-Based Standards and Expected Practices for Adult Local Detention Facilities (5th

Edition): 5-ALDF-2A-20, 5-ALDF-2B-04, 5-ALDF-4C-28(M), 5-ALDF-4C-29(M), 5-ALDF-

4C-31(M), 5-ALDF-4D-08(M), 5-ALDF-4D-11, 5-ALDF-4D-31(M), 5-ALDF-7B-08, 5-ALDF-

7B-10, 5-ALDF-7B-11

Records Retention Requirements

Requirements and retention guidance for records and information applicable to this program are

available in the Records and Information Disposition Schedule (RIDS) on the Bureau’s intranet

site.

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