WASHINGTON – When accused sex trafficker Jeffrey Epstein hanged himself while awaiting trial this month, it was the first recorded suicide at Manhattan’s federal detention center in 13 years.
But across the vast Bureau of Prisons, suicides have been gradually ticking up even as the overall inmate population has declined.
Twenty-seven federal inmates committed suicide in the fiscal year that ended in September 2018, the largest number in at least the past five years, according to prison system records. At least 21 inmates, including Epstein, have killed themselves in federal facilities since Oct. 1.
Though the death of Epstein, one of the highest-profile inmates in federal custody, triggered multiple investigations and a leadership overhaul at the BOP, suicide has long loomed as a challenge for the federal prison system and in many of the nation's state-run institutions. The deaths, according to court documents, are often driven by the same types of short-staffing and neglect that officials suspect could have been a factor in Epstein's ability to hang himself with a bedsheet in one of the government's most secure detention facilities.
Stanley Kogut hanged himself with a sheet in an Illinois federal detention center in 2014. His relatives claimed guards ignored signs he was in distress and failed to respond to other inmates' calls for help. Zachary Hill died of an apparent drug overdose in 2015. His mother said guards at a federal prison in Oregon failed to restrict his access to medications, despite a history of overdoses.
Cameron Lindsay, a former warden at three federal prisons, said staffing deficits and a lack of training probably contribute to more frequent suicides, as fewer or ill-prepared officers work longer hours and are unable to adequately monitor at-risk inmates.
"It's part of the problem, but the biggest problem is the vast majority of people don't care about prisoners who are largely seen as lesser than the average citizen," said Lindsay, a prison consultant. "I'm not saying that all (prison) staffers don't care; it's more about leadership setting the tone."
Amid the rising number of suicides, Epstein's death grabbed the attention of the Justice Department like no other prison fatality. The department launched three investigations, temporarily removed the warden of the jail where Epstein died and ousted the head of the federal prison system.
"We are moving expeditiously," Attorney General William Barr said Wednesday, discussing the case briefly in Dallas. "And I think soon I will be in a position to report to Congress and the public the results (of the investigation)."
The attorney general said investigators encountered some delays because witnesses requested union representation and lawyers. He reiterated that the case revealed "serious irregularities" at the detention center where Epstein died.
Trend toward more suicides
In Texas, where the prison population of 142,000 ranks second only to the federal system, prisoner suicides spiked last year at 40, the largest number in at least a decade, according to state records.
The surge, which prompted an internal review, has baffled state officials. As in the federal system, the Texas inmate population has declined in recent years.
"We really just haven't found anything," Texas Department of Criminal Justice spokesman Jeremy Desel said. "But it is something we are focused on."
In California, suicides have inched up in the past three years after three straight years of decline.
Perhaps the harshest spotlight has been cast on Alabama, where a federal judge slammed the state this year for failing to address a rash of prison suicides, citing 15 such deaths during a 15-month period beginning in 2017.
"The risk of suicide is so severe and imminent that the court must redress it immediately," U.S. District Judge Myron Thompson wrote in May as part of a lawsuit challenging prison conditions. "Unless and until (the state) lives up to its Eighth Amendment obligations, avoidable tragedies will continue."
The judge's ruling came a month after the Justice Department issued a scathing review of the prison system, concluding that inmates were routinely subjected to horrifying violence and sexual abuse within "a broken system" where people are murdered "on a regular basis."
Federal investigators who spent more than two years scrutinizing the prisons in a state that incarcerates more people per capita than almost any other found illegal drugs and weapons were rampant, cellblocks were overcrowded and dilapidated and the few poorly trained officers on duty appeared powerless to establish any semblance of control.
Some of the same problems have plagued the federal system, which has confronted severe staffing shortages for years that forced wardens to deploy hundreds of civilian workers to fill guard duty shifts and compel officers to work multiple overtime shifts.
Long hours and nurses on guard duty
This year, the attorney general told a Senate panel that the BOP struggled to fill up to 5,000 vacancies, a shortfall worsened by budget cuts and a government shutdown. Union officials said some officers have been saddled with three to four overtime shifts per week, while civilian staffers – including nurses, secretaries and cooks – have been pressed to fill vacant officer positions.
Kristan Morgan, a nurse at a Florida federal prison, told USA TODAY last year that she and other civilian staffers were routinely assigned to patrol cellblocks, including solitary confinement wings.
"We get a radio and set of keys, and we don't know which keys fit which doors," said Morgan, who has often reported to guard duty in nursing scrubs and running shoes because there are no extra officer uniforms.
Although lawmakers have warned that the "augmentation" deployments are dangerous, the BOP contended that all employees are regarded as "correctional workers first" in a statement provided to USA TODAY last year. All staffers are provided basic officer training as a condition of employment, but few civilians have been required to put that training into practice before they are tapped to plug security gaps.
Since Epstein's death in New York, law enforcement and prison union officials have acknowledged deep staffing shortages at the Manhattan facility and a heavy reliance on officer overtime to make up the difference. One of the two staffers working on Epstein's unit had worked multiple overtime shifts before Epstein's death. Authorities are examining whether the officers slept through required cell checks before the disgraced financier was found unresponsive in his cell early Aug. 10 and why he had not remained on suicide watch after an apparent suicide attempt days before.
The circumstances surrounding Epstein's death, though jarring, are not wholly unfamiliar.
A lawsuit in Illinois challenges the federal prison system's handling of a former Cook County sheriff's officer who hanged himself in 2014 within hours of being arrested and placed in the Metropolitan Correctional Center in Chicago.
The widow of Stanley Kogut claimed that prison officials failed to place her husband on suicide watch even though "it was readily apparent that (Kogut) was severely depressed and a danger to himself when he was processed into the MCC."
Amanda Kogut said her husband's arrest on robbery-related charges exacerbated his mental illness and "served to intensify his already severe depression."
Shortly after Kogut was placed in a cell, according to court documents, two other inmates housed nearby heard the sheriff's officer struggling as "it became readily apparent that Kogut was in the process of strangling himself."
"As they listened to Kogut gasping for breath and struggling in his cell, (the other detainees) began screaming and calling for any employee/agents of the MCC," the lawsuit contends, adding that at least 30 minutes went by before any staffer responded.
Jeffrey Neslund, an attorney representing the Kogut family, said some prison staffers were questioned as part of the case, and he seeks to interview others.
"Why a newly incarcerated police officer wasn't immediately placed on suicide watch or subjected to close monitoring is beyond me," Neslund said, adding that when an officer responded to Kogut's cell, the guard arrived with no key and had to call another officer to open the door.
"That's the kind of thing you hear about in a county jail," the attorney said. "It is bizarre."
Federal authorities, in written responses, denied the wrongful death claim and denied that Kogut's mental instability, if it existed at all, was apparent and should have prompted his placement on suicide watch. They disputed claims that Kogut's fellow detainees called for help and that the response was delayed.
"Deny," federal officials said repeatedly in court documents.
In Epstein's case, federal officials have made no such denials. In fact, Attorney General Barr has referred multiple times to "serious irregularities" in the Manhattan detention center where Epstein died. Barr temporarily reassigned the jail's warden days later, and two staffers assigned to Epstein's unit were placed on leave. Barr removed the acting head of the prison system Monday.
"I have never seen a warden reassigned after a suicide, let alone the removal of an acting director of the agency," Lindsay said. "It's unprecedented, but it needed to happen given the hyper-focus on this case."
If it hadn't been Epstein at the end of a bedsheet, some questioned, would the suicide have resulted in any action?
"What happened to Mr. Epstein was outrageous," said David Fathi, director of the American Civil Liberties Union's National Prison Project. "But in reality, it happens all the time."
This article originally appeared on USA TODAY: Federal prison suicides rising before Jeffrey Epstein's death