DOJ watchdog: federal prison not doing enough to prevent inmate suicides

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Lewisburg federal penitentiary in central Pennsylvania.

A federal facility in Pennsylvania has failed to take steps to reduce suicide risks among inmates — contrary to policies from the federal Bureau of Prisons and repeated reports from the Justice Department’s Office of the Inspector General, according to the latest federal review on the facility.

Lewisburg federal prison is a medium-security men’s institution located in central Pennsylvania, and thousands of inmates often pass through there on their way to other BOP-run institutions. A significant number of inmates there were being held in single cells — a prison practice where each cell is assigned to only one inmate.

A series of investigations by the BOP watchdog in recent years have documented major challenges within the federal prison syste officials there said they started addressing staffing challenges, which is responsible for the housing and care of close to 160,000 prisoners nationwide. In Lewisburg, 1,128 inmates are under the care of the BOP. The BOP has made some steps to address problems within its system, like broken or lacking security cameras in facilities, but serious issues remain.

The OIG has written repeatedly on the risks of housing inmates alone in a cell, which includes increased risks of suicide, Inspector General Michael Horowitz told NPR. The BOP says it disfavors this practice, Horowitz said.

“Yet as we go to prisons, we continue to see it occurring," he said.

This latest report, part of the OIG’s unannounced inspection program of facilities run by the BOP, unearthed a host of additional issues at Lewisburg. The BOP’s nationwide staffing crisis continues to be a problem in this facility, as does inmate healthcare quality, leaking infrastructure and employee conduct.

Lewisburg has previously been under the microscope by officials with the DOJ and the media. In 2016, NPR and The Marshall Project published an investigation into Lewisburg that found prison officials used restraints as punishment for prisoners who refused their cell assignments.

The report also found that prisoners with mental illness at Lewisburg were placed in solitary confinement, sometimes for far longer than recommended by BOP policy, usually with another prisoner who often also had a mental illness, putting them at a higher risk of assault and even death.

Horowitz: Single-celling a problem

In February, the OIG issued a report on deaths of inmates in BOP custody, finding that over an eight-year period, 344 inmates in federal prison died from suicide, homicide or accidents. The report followed the high-profile suicide of convicted sex trafficker Jeffrey Epstein, who died after being housed in a cell alone with ample bedsheets.

"We found in the past that single-celling creates the risks of suicide, inmate health issues beyond the mental health issues that result from being sometimes in lockdown 23 hours a day. Those can create cascading series of issues. Not just for the inmates, but also for the staff, because inmates who are in those conditions are more likely, on occasion, to react and act out in ways," Horowitz said.

The practice of housing inmates alone in a cell at Lewisburg was done when even when they were incarcerated in the prison's restrictive housing unit, where inmates are kept for 23 hours a day, exacerbating mental health issues, the OIG said.

From January 2022 through March 2024, Lewisburg had 16 suicide attempts, of which seven involved inmates who were single-celled at the time of their suicide attempt; five of these seven attempts involved inmates who were in restrictive housing when they attempted suicide. At the time of the OIG inspection, 13 out of 71 of Lewisburg’s restrictive housing inmates were in single-cell confinement, according to the report.

Prison guards were not equipped with tools that can cut down ligatures used by inmates to hang themselves. That's against BOP policy that states guards should be armed with those tools to respond quickly to inmates who have tried to harm themselves, Horowitz said. "We're finding over and over again, including at Lewisburg, that cut-down tools aren't readily available."

In its response to the findings, the BOP said Lewisburg has issued verbal and written reminders to staff about the requirement and have added more cut-down tools to an easier-to-reach location in case of emergency.

Antidepressant supply

The inspector general also raised concerns about how prison doctors handled inmate medications.

More than a dozen men who took antidepressants saw their medications abruptly stopped by a doctor who didn’t see them when they arrived at Lewisburg — putting them at a heightened risk for a major depression relapse, according to the report.

Inspectors reviewed medical records of 121 inmates who arrived at the prison, finding 24 had at least one of their prescribed medications stopped, while 15 of them saw their antidepressants discontinued by Lewisburg’s clinical director.

It’s usually recommended by medical professionals that patients taking antidepressants slowly taper off the drugs. The OIG’s report stated the risk for abruptly discontinuing the medications was greater than what the clinical director was concerned about, which included overprescribing.

Even if a man was being held at Lewisburg a short time while he awaited transfer to another facility, the clinical director said “when they’re here, they’re under my care.”

Because Lewisburg is a transitional prison, where inmates are at the facility for a few days or weeks before moving on to their new institution, having inmates abruptly taken off medication in this case "can obviously create risks, not only at Lewisburg, but at the next facility where the sentence defendant is going," Horowitz said.