Jail and Station Holding Cell Suicides, Attempted and Completed: Avoiding Allegations of Deliberate Indifference


Deliberate indifference can be defined as a “conscious or reckless disregard of the consequences of one's acts or omissions,” or simply put, “What did you know, when did you know it, and what did you do about it?” Without question, you will want to do all you can to avoid allegations and to defend cases of deliberate indifference in jail attempted and completed suicides.  I drew upon my personal experience working in large, maximum security jails with an average daily inmate count of 3,800 inmates.


I divided my recommendations into two areas of responsibilities:


• Administrative and Supervision


• Custodial Line Staff (sworn officers or civilian guards)


Here are my recommendations:


Administrative and Supervision


On going, verifiable, current staff suicide prevention training


A comprehensive suicide prevention plan must be designed to recognize, identify, monitor, and document those inmates who present a suicide risk during booking as well as during their jail housing.


It is essential to keep in mind that no matter how well written a suicide prevention plan may be, it is meaningless without having on-going, current, and verifiable suicide prevention training for the department’s personnel.


The training should at least include:


Jail suicide statistics


Warning signs and symptoms and other suicidal cues


How to identify an inmate who denies he/she is suicidal


Rick management of issues of suicide


Proper documentation of the training provided


Intervention procedures



Hang-proof or hang-resistant cells


Even in hang-proof and hang-resistant cells, motivated inmates can and do hang themselves.  I have personally cut down three inmates I found hanging in such cells.  Cells need to be free of anything that can be used as an anchor to tie off a noose.  Towel hooks should be removed.  The sink should have spigots and water handles designed so they can not be used as an anchor.  The grates in the air vents need to be very small so an inmate can not snake a torn sheet through it to anchor.  If the bunk is welded to the wall, care needs to be taken to eliminate the gap between the wall and side of the bunk.  I have seen inmates snake a flattened sheet into this gap to tie off.  Cells should be inspected regularly and have the inspections documented.


Hang-proof or hang-resistant cells


Even in hang-proof and hang-resistant cells, motivated inmates can and do hang themselves.  I have personally cut down three inmates I found hanging in such cells.  Cells need to be free of anything that can be used as an anchor to tie off a noose.  Towel hooks should be removed.  The sink should have spigots and water handles designed so they can not be used as an anchor.  The grates in the air vents need to be very small so an inmate can not snake a torn sheet through it to anchor.  If the bunk is welded to the wall, care needs to be taken to eliminate the gap between the wall and side of the bunk.  I have seen inmates snake a flattened sheet into this gap to tie off.  Cells should be inspected regularly and have the inspections documented.


Telephone cords


All telephone cords shall be at a length that prevents the potential for use as a ligature, no more than eight inches long.  I have seen inmates hang themselves on longer telephone cords.


Cell searches


Supervisors must ensure that regular and irregular cell searches be done and that the searches are documented in the appropriate log books. Supervisors need to inspect and sign off on these log books once a shift.  Oftentimes evidence of planned future suicides is found.


Improper treatment by mental heath and/or medical staff


Sometimes jail supervisors disagree with the level of treatment the jail’s mental and medical personnel provide to the inmates.  In cases where this is happening, the supervisors must not fail to act.  The supervisors need to document the evidence and send the documentation up the chain of command to the top jail administrator.  In cases where the supervisor feels the need to act is of an emergent nature, the paramedics need to be called and the inmate should then be taken to an outside medical center.  All of the actions of the supervisors must be documented.  More than once I have had to call for paramedics when the jail medical staff failed to take proper action.  If paramedics are called, the time of call needs to be documented in the jail’s main log book.


Suicide intervention kits


Supervisors must make sure these kits, which contain a cut-down tool, rubber gloves, towel, and large trauma bandages, are well placed throughout the jail.  It is the responsibility of the supervisors to ensure that the officers inspect the kits each shift and that the inspection is documented.


Intake booking interviews


Great caution needs to be exercised when interviewing a person who may have had or is having suicidal thoughts. Persons who are intent on harming themselves while in custody have an incentive to lie when asked if they are suicidal. When in doubt, always err on the side of caution and properly house the person under suicide watch.


Cell Checks and Log books


Supervision needs to inspect and sign the log books once a shift.  This inspection should not be done at the start of the shift.  If the log book is for a linear row of cells, the log book should be kept at the very end of the row so the officer doing the check must walk to the end of the row to write in the book.


It is essential for supervision to ensure the safety checks are being done on time and done properly.  One way for the supervisors to prove that the safety checks are being done is to inspect the log books every shift.


There is an old saying in police work:  “If it isn’t documented, it didn’t happen.”  When an attempted or competed suicide is discovered, supervision needs to take control of the concerned log books and log sheets as soon as possible and lock them down as evidence.  This way, the administration can defend against allegations of log tampering after the fact.


Supervision must train the officers that oftentimes suicide attempts occur just after the safety checks are done and that many attempts occur in the late afternoon and early morning hours.  Experience has also shown that suicide watch cell checks done every 15 minutes may not be enough.  Inmates have attempted and completed suicide right after a check was made. The staff must be aware of this.


Waiting to start CPR


Supervisors must ensure officers who discover inmates who are in cardiac arrest or not breathing either from hanging or other reasons do not wait for the medical staff to respond to start CPR.  Waiting for the medical staff to start CPR can be an act of deliberate indifference to the inmate’s welfare.  I have had cases where this as occurred.  There is no excuse for this.


Taking of personal photographs


Supervisors should not allow staff to take personal photos of attempted suicides or completed suicides.  Any photos taken need to be booked into evidence.  I have personal experience wherein staff members took photos for their own use (war stories) and there is no reason to do so.  The need to take personal photos is difficult to defend.  I had one case where a nurse witness testified she saw an officer taking personal photos of an inmate who had hanged herself before she was even cut down and treated.


Treat the location of a suicide as you would a crime scene


Once a suicide is discovered, the area needs to be locked down as if a homicide occurred.  No one enters the crime scene after the inmate was either removed or pronounced dead.  If the inmate is pronounced dead, do not touch the body.  Start a crime scene log and tape off the area.  Look for witnesses.  If witnesses are found, separate them.  Remember to identify and fully question persons who were in a position to see what happened even if they state they did not see anything.  Do not look for physical evidence until told to do so by the investigators.  Do not contaminate the scene.  Await directions from homicide detectives.


Suicide response drills


Jails supervisors need to hold regular, realistic, verifiable (documented) suicide response drills.  The drills should include:


- An inspection sheet quizzing the staff about policy and procedures in jail suicide and suicide prevention.


- Inspect suicide intervention kits.


- Response to a hanging, wrist cutting, overdosing, and verbal threats.  Look to see that the jail supervisors take a leadership role.


- CPR with a CPR dummy.


- Always include the medical staff in these drills.


- Ensure there are debriefings as well.  The debriefings should always include candid discussions about what went right, what went wrong, and lessons learned.


In house roll-call/briefings


Have routine distribution of bulletins about recent suicide attempts and about suicide prevention.  Document when the bulletins are handed out as well as when suicide prevention is discussed at roll-call/briefings.




It is one thing for a facility to have adequate policies and procedures to prevent suicides; however, it is quite another thing to have those policies and procedures actually followed.


Conduct audits regarding suicide prevention every year or every two years.  The audit ought to be conducted by personnel not assigned to the concerned facility.


The audit should cover:


- Proper housing for suicidal inmates


- Completion of safety checks


- Use of safety garments


-Distribution of training bulletins


- Full investigations of recent causal patterns and incidents of attempted and/or completed suicides


- Distribution of medications


- Relationships between the jail staff and the medical/mental health staff


- Knowledge of staff concerning compliance with policy and procedures


- Ensuring the facility is in state compliance with developing suicide prevention policies/plans


-The facility policies should be unit specific to the facility in regard to suicide prevention.


- Have the auditors randomly select two or three inmates currently under suicide watch and perform an audit of their case to ensure all of the policies were followed.


Ensure the audit findings are properly documented.


Internal Affairs Investigations


In serious suicide attempts and/or completed suicides, deliberate indifference may be shown if there was a lack of a full, complete, and objective investigation.  The role of Internal Affairs units must not be disregarded.  By default, Internal Affairs personnel are assigned outside of the custody facility and therefore tend to show more objectivity.  It is important to have Internal Affairs respond as soon as possible in these cases.  The failure to thoroughly and quickly investigate suicide attempts and/or completed suicides may show an effort by the department to ignore or bend the evidence to a predetermined conclusion that jail personnel followed proper policy and procedures.


Ensuring proper response by medical staff


In a medical/mental health emergency, supervision must ensure that sufficient medical personnel respond as needed.  Experience has shown that there have been cases wherein only one nurse responded while other nurses have opted to remain in the dining room rather than respond to assist in the emergency.  A needless delay in medical responses can show deliberate indifference.


Medical emergency equipment


Nursing supervision must look to see that their line nurses inspect their emergency medical equipment (oxygen tanks, for example) at the start of each shift and document that the inspection was done.  Experience has shown that in times of emergencies, nurses have responded with broken equipment.  There is no excuse for not checking all emergency medical equipment at the start of each shift.


Use of video


It is often not enough to do a good job; you have to prove you did a good job.  One way is the use of video cameras.  When dealing with a problematic inmate with suicidal tendencies, physical interactions between the inmate and custody staff should be videotaped as much as possible.  For example, if the inmate is to be removed from his cell and taken to an interview, and if the inmate has been violent in the past, the entire move should be videotaped.  It is important to start the video before the cell door is opened.  If the video starts after the cell door is opened and if there is a need for force and it was not captured on video, allegations of staff misconduct would be difficult to defend. The camera should not be shut off until the inmate is returned to his cell.  The videotape should then be dated and stored.  In all cases that are video taped, a supervisor needs to be present.


Low tolerance for potential suicidal behavior


Administration and supervision must be open-minded about any suicidal behavior.  All inmates who display suicidal behavior, no matter how slight, need to be quickly examined by the mental health staff and then have that examination properly documented.


Train line staff not to ignore complaints of depression and/or mental health issues.  Take the inmate directly to the medical/mental health staff at once and document it.


Feigned gestures


In cases of threats to commit suicide and/or feigned gestures (superficial marks, hesitation marks, injury does not support a life threatening injury, inmate has not displayed any desire to commit suicide) the inmate still needs to be quickly examined by the medical/mental health personnel and have the examination documented.


Consider discipline after the mental evaluation due to the inmate creating a false emergency.  I have personal experience that, by implementing discipline, feigned suicides dropped by 50% in a jail with an inmate count of 1,500.


If discipline is imposed, cross reference the medical/mental health report number with the discipline report number.


Manipulative and Impulsive Inmates


It can be very trying for the jail staff to be professional and concerned about suicide prevention when they know a certain number of inmates use the threat of suicide to manipulate them and the system. The staff should try to remember anyone who would slash his/her own wrists is emotionally unbalanced and needs professional help. Many people are immature and impulsive; they act without thinking about the consequences of their actions. For an inmate who uses suicide threats this type of behavior can be fatal. There have been inmates who have died when their fake suicide attempt went further than they wanted. All attempted suicides, however serious, must be reported at once to the medical and mental heath staff and properly documented.


Custodial Line Staff (Sworn Officers or Civilian Guards)


Medication supervision


While providing security for the medical staff when medication is given out to the inmates, ensure the inmate is actually swallowing the medicine.  Look to see that the inmate actually puts the pills in his/her mouth and swallows.  Inspect each inmate’s mouth to ensure this.  Do not let an inmate walk away with the pills in his/her hand.  This is one way inmates hoard medications and then later overdose on them.


Refusal of medications


If an inmate wishes to refuse his/her medication, the refusal must be face-to-face with the medical staff.  That refusal must be documented in the medical chart.


If the inmate refuses to exit his/her cell to make the refusal to the medical staff, have the medical staff go to the inmate and take his refusal at his cell.  Make sure the refusal is well documented.


Safety checks in the jail’s discipline housing area


The line staff should be aware that inmates in segregation/discipline often have higher levels of depression and suicidal ideation than inmates housed in general population.  For this reason, it is critical to perform safety checks at least every 30 minutes.


When observing the inmates who are in discipline (as well as anywhere in the jail), at the first hint of inmates suffering a psychiatric crisis, no matter how seemingly minor, the inmate needs to be taken immediately to see the medical/mental heath professionals.


The medical staff should conduct daily sick-call of the inmates in disciplinary cell housing.


Window covering


Never allow inmates to cover up their cell window.  Experience has shown that oftentimes when inmates cover up their window, they attempt suicide.  Never wait to have the covering removed.




While every effort has been made to ensure the accuracy of this information, it is provided for educational purposes and is not intended to provide legal advice.


About the author:


Richard Lichten (Lt. Retired) brings 30 years of front-line law enforcement experience to a wide range of police and jail topics. Twenty of his 30 years in the Los Angeles County Sheriff’s Department were in supervisory and command positions. Richard Lichten is deemed a qualified expert in the use of force, use of the Taser, police/jail practices, and jail/prison inmate culture in the State of California Superior Courts, State of Nevada Courts, State of Arizona Courts, State of Hawaii Courts, and in Federal Courts.

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