I am a forensic psychiatrist with experience and expertise in correctional health care administration and clinical practice. My area of expertise is suicide and wrongful death in jails and prisons. By researching and analyzing risk factors of suicide and developing prevention strategies, I have established considerable expertise in the field. As a consultant, I provide expert opinions and, if reasonable medical opinion, testimony on disputes such as standard of care, deliberate indifference, and civil rights violations. I have consulted on at least 70 cases under litigation in the United States and testified in at least 20 cases.

Introduction

During the last forty years, courts have attempted to address issues about legal liability related to suicide. The decisions cover various practices in jails and prisons, including diagnosis, monitoring, treatment, communication, policies, staffing, and training.

1          Inadequacy of mental health evaluation

In Comstock v. Mc Crary (1), psychologist Mc Crary did not perform an adequate psychological evaluation and risk assessment of an inmate who committed suicide. Had he done a detailed psychological evaluation, he would have known that several enemies who called him a snitch bothered the decedent.

2          Failure to identify obvious and substantial risk factors

In Williams v. Mehra (2), the significant issue involved a failure to identify an inmate’s substantial risk factors, including depression, psychiatric hospitalization, suicide ideation, and a previous suicide attempt with antidepressant tablets. The psychiatrists neglected to review the record that contained his diagnosis, suicidality, and specific treatment measure to address his suicidality, i.e., prescribing liquid medication.  Also, procedurally, the nurse failed to manage his medication on a watch take basis.

3                Psychotropic medication practice 

In Greason V. Kemp, (3), the Court held abrupt discontinuation of psychotropic medications of an inmate with a recent history of suicide attempts constituted deliberate indifference.  Greason killed himself in a Georgia prison. A doctor abruptly discontinued his antidepressant medication without reviewing his clinical file, conducting a mental status examination, or ordering close monitoring. The Court identified the department’s failure to train the staff, inadequate mental health care delivery, and delayed or denied treatment.

In Steele v. Shah, (4), a psychiatrist discontinued Steele’s psychiatric medications. Steele had a long history of depression, drug addiction, and attempted suicide twice before starting his long sentence.  The district court granted the psychiatrist’s motion for a summary judgment, indicating that his decision was nothing more than a disputed medical opinion. On appeal, the 11th  Circuit held that “psychiatric needs can constitute serious medical needs and that the quality of psychiatric care one receives can be so substantial a deviation from the accepted standards as to evidence deliberate indifference to serious psychiatric needs.”

4          Officers’ failure to communicate an arrestee’s suicide statements

In Gordon V. Kidd (5), the Court established that failure by an arresting officer to communicate to booking officers constitutes deliberate indifference.

In Conn v. City of Reno, (6) the Court of appeals reversed a district court’s grant of summary judgment in favor of two officers because there was “sufficient evidence to create a genuine fact regarding defendants’ “subjective awareness” of a serious medical need. 

In Freedman v. City of Allentown, (7), in contrast to Gordon v. Kidd and Conn v. City of Reno, the Court decided that a probation officer’s knowledge of an arrestee’s previous suicide attempt did not reach the threshold of deliberate indifference when he did not inform the arresting officer. Therefore, his actions were not intentional, malicious, or reckless, and “at most the averments against the officer amount to a lack of due care and are not actionable as a 1983 claim.” 

5          Suicidal ideation, suicide watch, and logging 

Mental health professionals often release inmates who deny suicidal ideation from suicide watch.  Some inmates intentionally conceal their true intentions after they make their decision to exit the world. 

In Woodard v. Myres, (8), the claims centered on the failure to institute standard suicide watch, lack of suicide watch monitoring and logging, premature discontinuation of suicide watch, and noncompliance with the facility’s policies and practice.

In Simmons v. Navajo County, (9) the Court opined that placing a pretrial detainee on suicide watch, even the highest level, standing alone “does not demonstrate that an official was subjectively aware of a substantial risk of imminent suicide.”  As per Simmons ‘ Court, determinants of imminent suicide risk include “observed suicidal actions, heard statements of suicidal, or witnessed evidence of suicidal intent,” indicating a strong likelihood of suicide.

In Hott v. Minnesota (10), falsification of suicide watch by an officer resulted in an unfavorable court decision for the officer.  

In Minix v. Canarecci (11), the district court opined that there was enough evidence to allow a jury to find a direct causal link between the Jail’s practice of classifying and releasing detainees from suicide watch and suicide.

In Broughton v. Premier Health Care Servs., (12), the issue was intentional concealment of suicidal ideation, making it difficult to stake a successful claim against correctional officials. The Court opined, “While Broughton’s disclaimer of suicidal ideation does not automatically insulate the defendants from liability, it does undermine the claim that they willfully ignored his past medical history and current symptomology.”

Strickler V. Mc Cord (13) illustrates the difficulty for jail officials charged with the care of inmates who are determined to commit suicide.  The Court found, “He lied on the intake form; he lied when questioned about suicidal thoughts at the Bowen Center, and he deceived the guards about his medication and the razor blades.” 

6          Recent Suicide attempt and failure to get prior medical records.

A recent suicide attempt is the most significant predictor of suicide. The courts have not opined on the recency of suicide attempt relevant to a liability claim. Clinically, a near-lethal suicide attempt within six months to a year has the most predictive value.  Failure to question an inmate about history of past suicide attempts can lead to potential liability. While some inmates intentionally withhold the information, the prior records serve as the most reliable vehicle to get such information. To prevail in a lawsuit, a plaintiff must establish the decedent previously made near-lethal suicide attempt/s/ 

In Terry v. Rice (14), County officials went out of their way not to collect information from the prison where the decedent was transferred, presumably for “safekeeping.”  In denying the summary judgment, the Court opined, “Going out of your way to avoid acquiring unwelcome knowledge is a species of intent. Being an ostrich involves a level of knowledge sufficient for a conviction of crimes requiring specific intent.”

In Mc Kee v. Turner, (!5) the treating psychiatrist was sued for failing to get prior jail records that indicated that the decedent had attempted suicide by hanging six weeks before he arrived at the prison. The dissenting judge opined, “McKee is distinguishable in one specific aspect, i.e., failure to obtain medical records.”  

7          Diagnosis and Treatment Issues 

Prisoners have claimed several diagnostic and treatment issues to support § 1983 claims. 

a)        Diagnosis of Mental illness

The diagnosis of a mental disorder or failure to diagnose per se does not support a claim of liability. While inmates diagnosed with depression, anxiety, and bipolar disorder have a high degree of suicidal propensity, unless indicators of suicide vulnerability accompany the diagnosis, the claim is not sustainable.   

 The Courts have held that displays of erratic behavior or signs of mental illness, without specific indicia of suicidal tendency, “do not rise to the level of a serious risk of suicide” and do not provide “the level of notice” required to trigger the deliberate indifference standard (16, 17)   

b)        Incorrect diagnosis

In Steele v. Choi (18), the Court concluded incorrect diagnosis or improper treatment does not support an Eighth Amendment claim. In affirming a summary judgment in favor of Dr. Choi, the 7th Circuit opined, “Estelle requires us to distinguish between `deliberate indifference to serious medical needs on the one hand, and `negligence’ in diagnosing or treating a medical condition.”

c)         Intentional refusal to provide medical care.

Courts have acknowledged that intentionally refusing to respond to an inmate’s complaints, including repeated requests to see a mental health professional constituting deliberate indifference. Thus, to prevail, the plaintiff must establish the providers intentionally refused to provide medical care or denied access to a physician. Further, such refusal must cause the inmate undue suffering or threat of injury.

d)        Delay in treatment

Courts have established that repeated delays in treatment of medical or dental conditions support a claim of deliberate medical indifference (19, 20). However, isolated delays or delays due to the natural course of events in a facility and administrative procedures, not an uncommon occurrence in a correctional setting, may not be actionable.  

Delay of treatment claim depends on the length of delay, the nature of the medical need, and the reason for the delay (16)   In Harris v Coweta County, (21), the Court held that such “a delay created a genuine issue of material fact about deliberate indifference.”

Delay in responding to repeated requests to see a mental health professional by a potentially suicidal inmate may result in a liability claim.   In O’Quinn v. Lashbrook (22), the Court decided a claim of delayed treatment was meritorious.

e)        Improper medication or modality of treatment

Improper medication treatment and medical supervision by the psychiatrist can support a claim of deliberate indifference if it can be proved such improper medication treatment cause suicidal ideation and serious injury resulting in death. Prisoners are not entitled to a specific prescription or modality of treatment if the choice of medication prescribed by the physician or the modality of treatment addresses his medical need.

f)         Inadequate treatment

In Durmer V. O’Carroll, (23), the Court opined that all inadequate treatment provided to a prisoner could not be construed as deliberately indifferent. Instead, it can simply be “no more than mere negligence.” The Court further opined a failure or delay in providing prescribed treatment if deliberate and motivated by non-medical factors, a constitutional claim may be presented.

In Arenas v. GA Department Corrections, (24), the Court found that a failure to provide adequate treatment to a young inmate with a longstanding history of depression and bipolar disorder constituted deliberate indifference.

       g)  Inadequate monitoring of inmates in administrative segregation

Periodic reviews of inmate’s suitability to continued stay in administrative segregation is a standard procedure.  Courts have recognized “substantial risk of psychological harm and decompensation posed by extended placement in segregation” including anxiety, panic, paranoia, depression, PTSD, psychosis, and disintegration of a basic sense of self-identity (25, 26)

8)         Policy, staffing, and training 

In many deliberate indifference lawsuits, counties face Monell claims related to suicide prevention policy, mental health and correctional staffing, and training.

1.    Absence of suicide prevention policy   

In White v. Watson (27), the Court opined that the absence of suicide prevention policy and lack of training and supervision were “the moving force behind the failure to protect the inmate from the known risk of suicide in the Jail.  

Other Court decisions show that for a successful claim based on the absence of suicide prevention policy, evidence must be presented to show a pattern of suicide or suicide attempts.

         2)        Policy or custom causing or contributing risk of harm.

In Gibson v. County of Washoe, (28) the Ninth Circuit opined that County’s failure to respond to the decedent’s urgent need for medical attention was a direct result of “an affirmative County policy that was deliberately indifferent, under the Farmer standard, to this need.”

In Gates v. Cook (29), the Court noted multiple policies or practices that combine to deprive a prisoner of a “single, identifiable human need,” such as mental health care, can support a finding of Eighth Amendment liability.

          3)        Shortage of staff

In Bragg v. Dunn (30), the Court found persistent and severe mental-health and correctional staff shortages, combined with chronic and significant overcrowding, as the “overarching issues that permeate” the contributing factors of inadequate mental health care and suicide.

            4)        Failure to Train

Failure to train the staff focuses on the U.S. Supreme Court’s decision in City of Canton v. Harris  (31). A County can be found deliberately indifferent if it fails to train officers to recognize suicide indicators, policy issues, monitoring procedures.   Officers cannot be held liable for deliberate indifference “unless an inmate was so obviously mentally ill that the deputies, who had received no training regarding the diagnosis and treatment of mental illness, must have known that [he] was exhibiting symptoms of mental illness” (28)

Conclusion

The court decisions noted above provide valuable insights and directions to develop appropriate risk management strategies in jails and prisons.

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Note: This article is abstracted from my book in preparation, titled, “Suicide in Jails and prisons: preventive and legal perspectives.

References

• Comstock v. Mc Crary, [2001], 273 F.3d 693, 6th Cir
• Williams v. Mehra [1999], 186F, 3d 686,690,6th Cir
• Greason v. Kemp, (1990) 891 F.2d 829 (11t h Cir
• Steele v. Shah, [1996], 87 F 3rd 1166, 11th Cir
• Gordon v. Kidd, (1992) 971 F.2d 1087, 1095, 4th Cir
• Conn v. City of Reno, 591 F.3d at 1105, 9th Cir
• Freedman v. City of Allentown (1988) 853 F.2d 1111, 1117, 3d Cir
• Woodward v. Myres, (2002) No. 00 C 6010, 99 C 0290, at *1, N.D. Ill.
• Simmons v. Navajo County, (2010) 609 F.3d 1011, 1018, 9th Ci
• Hott ex rel. Estate of Hott v. Hennepin County, (2001) 260 F3d 901, 8th Cir   
• Minix v. Canarecci, (2010) 597 F.3d 824, 833, 7th Cir
• Broughton v. Premier Health Care Servs Inc, (2016), No. 15-4150, 6th          Cir
• Strickler v. McCord, (2004) 306 F. Supp. 2d 818, N.D. Ind
• Terry v. Rice, (2003) CAUSE No. IP00-0600-C K/H, at *1, S.D. Ind
• McKee v. Turner, (1997) No. 96-3446, 1997 WL 525680, *3, 6th Cir
• Jackson, 787 F.3d at 1354-56.
• Cavalieri, 321 F.3d at 621
• Steele v. Choi, (1996) 82 F.3d 175, 178, 7th Cir
• Gutierrez v. Peters, (1997) 111 F.3d 1364, 1371, 7th Cir
• Hunt v. Dental Dept. (1989) ,865 F.2d 198, 200, 9th Cir 
• Harris v. Coweta County, (1994) 21 F.3d 388, 393-94, 11^th
•  O’Quinn v. Lashbrook,(2019) No. 18-cv-2013-SMY, S.D. Ill
• Durmer v. O’Carroll, (1993) 991 F.2d 64, 69, 3d Cir
• Arenas v. Ga. Dep’t of Corr, (2020) No. CV416-320, at *2, S.D. Ga.
• Palakovic v. Wetzel,(2017) 854 F.3d 209, 225-26, 3d. Cir.
• Braggs v. Dunn, (2019) 367 F. Supp. 3d 1340, 1344, M.D. Ala
• White v. Watson, (2016) No. 16-cv-560-JPG-DGW, S.D. Ill.
• Gibson v. County of Washoe, (2002) 290 F.3d 1175, 1189, 9th Cir
• Gates v. Cook,(2004) 376 F.3d 323, 333, 5th Cir
• Braggs v. Dunn, (2017) 257 F. Supp. 3d 1171, M.D. Ala
• City of Canton v. Harris, (1989) 489 U.S. 378