Strengthening the U.S. Medicolegal Death Investigation System: Lessons from Deaths in Custody (2025)
Chapter: 4 Carceral Health and Deaths in Custody: Types, Causes, Manner, and Response
4
Carceral Health and Deaths in Custody: Types, Causes, Manner, and Response
As stated in Chapter 1, cause of death is the medical condition or injury that led to an individual’s death, whereas manner of death is a classification that describes how an individual died (Hanzlick, Hunsaker, and Davis, 2002). An effective medicolegal death investigation (MLDI) system provides insights into the overall health (as well as circumstances and causes of injury) in affected communities. A reduction in deaths in custody requires an understanding of factors involved in natural and unnatural deaths.
CARCERAL HEALTH
In-custody deaths due to violence or suicide garner significant public attention, but available data indicate that most reported in-custody deaths result from illness or disease.1 These data indicate that infectious diseases, chronic illnesses, mental health disorders, and substance use disorder are common health issues in carceral settings and that those in custody have a higher prevalence of health conditions than the general population. The higher prevalence of health conditions in the incarcerated population is, in part, a reflection of the fact that the incarcerated population has a high
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1 From 2001 to 2018, 87 percent of reported state prison deaths and 90 percent of federal prison deaths were due to illness (BJS, 2021c).
concentration of people with low incomes, “who are more likely to be medically underserved” (Dumont et al., 2012, p. 327; Hammett, 2006).2
Infectious diseases may have been contracted prior to incarceration, but factors common in carceral facilities (e.g., overcrowding, poor sanitation, and limited access to health care) fuel the spread of communicable diseases. It is estimated that 17 percent of those incarcerated in state facilities and 10 percent of those incarcerated in federal facilities have had infectious diseases such as tuberculosis, hepatitis C, or HIV infection (BJS, 2021a).3 While a 2016 Bureau of Justice Statistics (BJS) survey found that 10 percent of those in state custody and 4 percent of those in federal custody reported ever having hepatitis C, the most common infectious disease reported, this is likely an underestimate (BJS, 2021a).
Chronic conditions such as hypertension, diabetes, and asthma are also common in carceral facilities, and more common than in general populations (Binswanger, Krueger, and Steiner, 2009; BJS, 2021a). The 2016 BJS survey indicated that 40 percent of those in state custody and 33 percent of those in federal custody had a current chronic medical condition (BJS, 2021a). The most common chronic conditions reported were high blood pressure (29 percent), arthritis (17 percent), and asthma (16 percent) (BJS, 2021a). Nearly 87 percent of those in state custody and 89 percent of those in federal custody who died in custody from 2001 to 2019 died of illness (BJS, 2021d).
Mental health issues are also common in correctional facilities. According to BJS, an estimated 37 percent of those in state and federal custody and 44 percent of those in jail have been diagnosed with a mental disorder (BJS, 2017). Conditions such as depression, anxiety, post-traumatic stress disorder, and schizophrenia are prevalent, and inadequate mental health services in jails and prisons contribute to worsening symptoms (Mental Health America, 2015). The stressful and sometimes violent environment of prisons, along with solitary confinement or other forms of social isolation imposed as a form of punishment, can further compound mental health issues.
Substance use disorders affect a significant proportion of the incarcerated population. The National Institute on Drug Abuse (NIDA, 2020) estimates that 65 percent of the U.S. prison population has an active substance use disorder. BJS reported that in state prisons, drug overdoses and
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2 See also NASEM, 2020.
Khatri and colleagues (2025) found in a “nationally representative cohort study of approximately 3.26 million adults observed from 2008 through 2019,” that “individuals incarcerated at the time of the survey experienced a 39% higher risk of all-cause mortality and more than 3 times the risk of overdose mortality compared with nonincarcerated individuals. County incarceration rates were also associated with increased all-cause mortality risks, even for nonincarcerated residents.”
3 Such conditions are particularly prevalent in incarcerated populations.
alcohol intoxication were responsible for 2.3 percent of all deaths from 2001 to 2019 (BJS, 2021d). The limited availability of comprehensive addiction treatment programs and the availability of contraband illicit drugs in prisons contribute to a cycle of substance abuse and related health complications.
Carceral Health Care Providers
Unlike unincarcerated Americans, incarcerated persons are constitutionally entitled to adequate physical and mental health care, and the government cannot be deliberately indifferent to serious medical needs of incarcerated individuals. The Health Services Division of the Bureau of Prisons (BOP), which serves over 150,000 individuals in federal facilities across the country, is one of the largest health care providers in the United States, spending $1.34 billion for health care in 2016 (GAO, 2017).
“BOP policies and procedures require certain actions and reports in the event of an inmate death,” but a February 2024 report from the U.S. Department of Justice Office of the Inspector General (OIG) found that, for many deaths, “BOP was unable to produce documents required by its own policies” (OIG, 2024). Moreover, OIG (2024) observed that BOP’s policy calls for after-action reviews following inmate suicides but not following inmate homicides or deaths resulting from accidents, unknown factors, or natural causes. Notably the OIG’s report was limited to a review of deaths resulting from suicides, homicides, accidents, or unknown factors and did not consider deaths from natural causes. However, in 2019—a typical year among the years examined in the report—the mortality rate attributed to natural causes (259 per 100,000 residents) vastly eclipsed the mortality rate from any of the causes the OIG examined (7–20 per 100,000 residents) (BJS, 2021d). For these reasons, BOP has limited understanding of the circumstances that led to these deaths in custody and limited ability to identify steps for preventing future deaths (OIG, 2024, p. ii).
With one exception,4 the cost of health care provided in carceral facilities is not covered by public or private insurance (Avila, 2022). Instead, costs are borne by the budget of the government entity that operates the facility; health care provided to incarcerated individuals thus becomes the fiscal responsibility of that entity. Most facilities attempt to recover some of the cost of health care directly from those who are incarcerated, typically
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4 Health care provided to Medicaid-eligible individuals in a nonpsychiatric hospital in the community is covered by Medicaid if the patient is admitted to the hospital for at least 24 hours. The Centers for Medicare & Medicaid Services (CMS, n.d.) have, however, authorized “demonstration projects under section 1115 of the Social Security Act (the Act) (42 U.S.C. § 1315) to improve care transitions for certain individuals who are soon-to-be former inmates of a public institution… and who are otherwise eligible for Medicaid.”
through copayments ranging from $2 to $5 (Herring, 2022). Some facilities also attempt to recover the full cost of interventions that required cash outlay by the facility (e.g., for medication and emergency room visits). McKillop (2017) reported that for fiscal year 2015,
the typical state department of corrections spent $5,720 per inmate to provide health care services, including medical, dental, mental health, and substance use treatment. . . . Departments in four states (California, New Mexico, Vermont, and Wyoming) spent more than $10,000 per inmate, while five [states] (Alabama, Indiana, Louisiana, Nevada, and South Carolina) spent less than $3,500 per inmate.5
Health care in carceral settings is often contracted to private companies (Szep et al., 2020). Investigations and lawsuits have uncovered systemic issues with private health care services, including delays in treatment, inadequate medical staffing, and poor mental health services (ACLU Delaware, 2023). These problems are often linked to profit-driven incentives that prioritize reducing per capita expenses over the well-being of incarcerated individuals (Tucker, 2016). However, while privatization may exacerbate problems in instances where health care is substandard (by diverting funds that would have gone directly to health care to company profit margins), a focus on privatization as the cause of poor health care may be misplaced. Other confounding factors such as inadequate funding are likely causative. Indeed, as pointed out by Reuters (see Box 4-1), jurisdictions that contracted with private companies were more likely to have lean budgets (Tucker, 2016).
Carceral Health Care Challenges
Individuals entering carceral facilities are arguably sicker than any other group in general populations, carrying a higher burden of mental illness, substance use disorders, communicable diseases, and noncommunicable chronic medical diseases and having had less contact with the health care system prior to incarceration. Despite these needs, those in custody
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5 “As of February 2022, all federal prisons and 40 states charge incarcerated people a copay when they initiate medical care. The average cost falls around $2, a deceptively low price tag that obscures the financial scarcity that many incarcerated people and their families live with. Average prison wages tend to be low—according to a report by the American Civil Liberties Union, incarcerated people earn between 13 cents and 52 cents per hour and in seven states aren’t paid at all for most work assignments. Additionally, incarcerated people are taxed up to 80% of those wages for ‘room and board,’ court costs, restitution, and other fees like building and sustaining prisons.” Also, in some states, not everything is covered by copays—medications and additional treatment may incur other fees, all of which can quickly pile up, especially for conditions that require regular visits. This means that incarcerated people often require an entire month’s pay to afford covering a single copay (Avila, 2022).
BOX 4-1
Private Health Care and Mortality in Carceral Facilities
In 2020, Reuters published an investigative report on mortality rates in private correctional health care systems. It reported that a few companies provide most of the health care in jails: Wellpath Holdings, Inc., which is owned by a private equity firm; Corizon, which is owned by an investment firm; and NaphCare Inc., PrimeCare Medical Inc., and Armor Correctional Health Services Inc., which are privately owned.
The Reuters survey included 523 jails and captured health care and death data from 2008 to 2019. It included “all U.S. jails with 750 or more inmates, plus the 10 largest jails in nearly every state” “to assess privatization’s impact on inmate mortality. . . . From 2010 to 2015, death rates were generally similar in jails using the big healthcare contractors and those with publicly managed care,” but death rates diverged from 2016 to 2018.
- Jails using the major companies had 691 fatalities among an average total population of 138,000 individuals in that 3-year span.
- Jails using publicly managed care had 587 fatalities while caring for more than 152,000 individuals.
The survey indicated that, on balance, death rates are higher when health care is in the hands of private industry and that, “overall, facilities with care managed by the biggest jail medical providers had 17 deaths per 10,000 inmates, compared to 13 deaths in publicly-run units” (Reuters, 2020).
Reuters found that contracts with private providers “sometimes lack quantified standards for care, such as staffing requirements or protocols for inmate health evaluations or hospitalizations” though “such problems can occur in publicly run systems” (Reuters, 2020). Further, “big jurisdictions are more likely to have publicly managed inmate care under the aegis of a health department, Reuters found,” but “small to midsize counties, often operating with tight budgets, are more likely to hire private firms” (Reuters, 2020).
often face health care challenges due to inadequacies in carceral health care services (Alsan et al., 2023; NASEM, 2020).
Notwithstanding the constitutional mandate, health care is consistently provided for only a fraction of those in custody who need it. While the reasons are myriad, complicated, and poorly studied, they can be grouped under four themes: funding and resource issues, prevalence of mental health and substance use disorders, mission, and oversight.
Funding and Resource Issues
Many facilities struggle to provide adequate health care due to inadequate funding, which can lead to inadequate medical facilities, staffing issues, or medical neglect. As noted above, carceral health care is not covered by insurance. Instead, carceral care is funded by government budgets that also must finance all other competing community needs.6
Inadequate funding for health care leads to insufficient numbers of funded health care positions; high vacancy rates due to low salaries; the hiring of less-qualified staff (Adams, 2021); “downshifting” of clinical tasks to staff with lower credentials (e.g., assigning assessment of episodic clinical complaints to nurses instead of physicians); and the inability to attract health care providers to consult at the level of compensation offered by the carceral facility. It has also led to construction of facilities with inadequate physical space to provide health care and may contribute to limitations in treatments such as testing and medications (Wilper et al., 2009).
Funding gaps are most pronounced in small rural jails, which are unlikely to employ any health care professionals. At intake, assessments of an individual’s medical and mental health status are usually conducted by corrections officials. Access to health care requires corrections officials to recognize that a health care problem exists and then, typically, to transport the individual to a hospital emergency room. As a result, health care—if it is provided—is fragmented, focused on urgent needs, and may be inadequate. The mortality rate in small jails (those with fewer than 50 residents), for example, is reportedly 64 percent higher than in large jails (those with more than 2,500 residents) (BJS, 2021b).
In carceral settings, health care for urgent and nonurgent episodic needs is largely provided by nurses (e.g., registered nurses, licensed practical nurses, vocational nurses). When a patient submits a request to be seen for a clinical concern, they are typically seen by a nurse who examines them and makes an assessment, acting independently of a physician. The nurses may, at their discretion, provide treatment (e.g., by providing over-the-counter medications, or, in some jurisdictions, prescription medications) and discharge the patient or refer the patient to a facility physician, community health care provider, or hospital.
Given the inadequacies of medical care in carceral settings, it is not uncommon to see potentially serious conditions misdiagnosed, mistreated, or neglected—sometimes with fatal results (Tiernan, 2022; see Box 4-2).
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6 In one instance, a federal court study in Arizona found that there was a $75 million gap between what the state legislature allocated for the provision of health care in the state’s prisons and how much the state should have allocated to meet the needs of its incarcerated population (Stern, 2019).
BOX 4-2
Medical Neglect in Carceral Facilities
Business Insider “analyzed a sample of nearly 1,500 federal cases alleging cruel and unusual punishment in violation of the Eighth Amendment…and citing the relevant precedent-setting Supreme Court cases and standards. Nearly two-thirds of those cases involved allegations of constitutionally inadequate medical care. Among them were claims of grievous harm: untreated infections so severe they resulted in amputations; deaths from treatable conditions like gallstones or appendicitis; and agonizing months and years spent waiting for diagnosis and treatment as cancerous tumors swelled, metastasized, and grew lethal. Hundreds of prisoners complained of inadequate treatment for potentially fatal illnesses such as hepatitis C and HIV or said their mental-health crises were met with violence or solitary confinement rather than care. Dozens said they experienced excruciating pain—stemming from conditions such as collapsed vertebrae or severe infections—that went untreated for months or years. Still more said they were denied basic medical accommodations such as dentures and walkers” (Becker and Einbinder, 2024).
The case of Dana Huff is illustrative. Huff was sent to state prison in Florence, Arizona, in May 2019 for an aggravated driving under the influence charge (Jenkins, 2020). In remarks to the committee, Corene Kendrick, deputy director, American Civil Liberties Union National Prison Project, said that at the time of his incarceration, Huff had a small lump on his cheek and “medical staff told him it was a wart or a mole or a pimple but nothing to worry about. His case and requests for specialty consults [subsequently] fell through the cracks during the changeover between the for-profit correctional health care companies Corizon and Centurion.” By the time he was finally sent for specialist care, Kendrick said, the lump had become a large, “inoperable cancerous tumor that was wrapped around his facial nerves” and spread throughout his skull forcing one eye shut. Kendrick recounted that the Arizona Justice Project at Arizona State University assisted Huff with an application for commutation on the basis in of the state’s “imminent danger of death exception,” and Huff’s commutation was unanimously approved by the Arizona Board of Clemency on February 12, 2020. Huff was released and died at home. His death was not counted as a death in custody.
Prevalence of Mental Health and Substance Use Disorders
When entering a carceral facility, individuals undergo an initial health assessment, but these evaluations are often cursory and can fail to identify mental health issues. Intake processes frequently lack comprehensive mental health screenings, leading to underdiagnosis and untreated conditions (Fazel et al., 2016). Even when mental health issues are identified, continuity of care is often disrupted when an individual enters custody. Incarcerated individuals may not receive follow-up assessments, and mental health conditions can deteriorate without appropriate medication or intervention. The
transient nature of the jail population, with frequent transfers and releases, further complicates the ability to provide continuity of mental health care.
Access to mental health treatment in carceral facilities is limited along at least two dimensions: staffing and medications. Many carceral facilities have a shortage of qualified mental health professionals. Incarcerated individuals often receive only the most basic mental health services, such as limited counseling sessions or psychotropic medications, and may not receive comprehensive treatment plans.7 Cognitive-behavioral therapy, psychoeducation, and other evidence-based treatments are rarely available, leaving many without the necessary tools to manage their conditions. Lack of proper care can result in an increased risk of self-harm or suicide (LeMasters et al., 2023). Further, the stigma associated with mental illness or the fear of being seen as weak or of being placed in solitary confinement can discourage those in custody from seeking help.
It is sometimes difficult to get incarcerated individuals to adhere to their medication regimes. The use of psychotropic medications can be disrupted if a medication taken preincarceration is unavailable at a facility’s medication formulary. In such cases, carceral staff may stop providing the medication or provide another less effective medication. In some instances, facilities may charge co-pays for medications or charge those in custody the full cost of a medication, which may lead some individuals to opt out of treatment to avoid incurring costs for prescriptions that can amount to hundreds or thousands of dollars.
The neglect of mental health in carceral facilities has tragic consequences. BJS (2021e) reported that from 2000 to 2019, there were over 6,200 suicide deaths in local jails. In state and federal prisons, around 4,500 individuals died by suicide during the period from 2001 to 2019. The number of suicides increased 83 percent over that period. The suicide rate in local jails tends to be high, particularly during the initial period of incarceration. More than three-quarters of those in jails who died by suicide from 2001 to 2019 were preadjudication of their current charge (and therefore technically innocent of their charge). Nearly half (46 percent) of those who died by suicide in local jails had been held for 7 days or less at the time of death (BJS, 2021e).
Drug overdose deaths inside U.S. carceral facilities have surged in recent years to become a leading cause of death among the incarcerated. A significant factor contributing to this trend is the increasing prevalence of opioids, including synthetic opioids like fentanyl, which are often smuggled into correctional facilities, in combination with a lack of available
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7 According to the National Alliance on Mental Illness, “about 3 in 5 people with a history of mental health illness do not receive mental health treatment while incarcerated in state and federal prisons” (NAMI, 2025).
medications for treatment of opioid use disorder (see, e.g., The Center for Health and Justice Transformation, 2025; NASEM, 2019).8 From 2001 to 2018, the number of individuals who died of drug or alcohol overdose in state prisons rose more than 600 percent. Overdose deaths in county jails increased by more than 200 percent (Schwartzapfel and Jenkins, 2021).9
Some deaths classified as due to alcohol or opioid toxicity are in fact due to withdrawal. It is well recognized that death can occur from withdrawal from alcohol or benzodiazepines. Deaths from opioid withdrawal are a less well-recognized phenomenon that has been documented in carceral populations (Darke, Larney, and Farrell, 2017). Of 1,442 deaths associated with drug and alcohol in the United States from 2000 to 2013, more than 103 deaths were associated with withdrawal. While most of the withdraws involved alcohol, “21 involved drugs (primarily opioids), and among 16 . . . there was reference to withdrawal/detoxification, but data were lacking regarding the substance, that is, drugs or alcohol” (Fiscella et al., 2020). Opioid withdrawal–related deaths may have increased incidence in carceral settings for three reasons. First, individuals experiencing withdrawal in other circumstances (e.g., following treatment for a severe injury or other illness) are typically already in an inpatient hospital setting where their withdrawal can be medically managed. Second, carceral facilities have been “slow to add [medication-assisted treatment for opioid use disorder] to their treatment regimens” (NCCHC and National Sheriffs’ Association, 2018, p. 6). Third, if an individual attempts self-withdrawal independently in a community setting, that individual would typically have unrestricted access to fluids to counteract dehydration associated with withdrawal. Further, in the event of severe withdrawal-related illness, these individuals can elect to remedicate themselves with opioids.
Overdose and alcohol or opioid withdrawal deaths are sometimes difficult to distinguish based solely on examination of the body and laboratory tests (Dyer et al., 1999, 2001).10 Absent careful inquiry into the circumstances surrounding the death (e.g., interviewing carceral staff and other incarcerated individuals, reviewing medical records and video footage), a
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8 “According to a review conducted by the Jail & Prison Opioid Project in July 2021, just 632 of the approximately 5,000 correctional facilities (12%) offer any medication to treat opioid use disorder” (Rising, Whaley, and Saloner, 2022).
9 For individuals with opioid use disorder in “the criminal justice system, a lack of access to medication-based treatment leads to a greater risk of returning to use and overdose after they are released from incarceration.” Further, individuals with a history of opioid use disorder “have a demonstrably high risk of mortality following release from incarceration” (NASEM, 2019).
10 Correspondence dated July 11, 2025, from Maureen Boyle, Chief Quality and Science Officer, American Society for Addiction Medicine (ASAM), on behalf of ASAM addiction specialists.
death from poorly managed withdrawal may be incorrectly classified as caused by overdose or even natural disease.
Federal death-in-custody data do not currently indicate whether deaths are the result of alcohol or opioid withdrawal. Rather, these deaths are folded into the category of death by illness. Absent specific data about withdrawal deaths, their prevalence is unknown.
An analysis of deaths that occurred from 2015 to 2021 in some 130 carceral facilities across Louisiana paints a grim picture of the costs of ignoring the mental health crisis in jails and prisons. The study revealed significant spikes in suicide rates, particularly within parish jails, for both pretrial and convicted populations (Incarceration Transparency, 2023a). Many suicides occurred while individuals were held in solitary confinement, raising concerns about the ability of corrections officers to identify distress signs early enough to prevent fatalities. The study also found that drug-related deaths were also on the rise.11
Because carceral facilities are not responsible for the costs of medical treatment once an individual is no longer in custody, some facilities try to return individuals with costly conditions to the community prematurely to reduce the costs of providing health care (Carda-Auten et al., 2022). In cases of individuals with terminal illnesses, the release process for prisons is lengthy and typically requires the involvement of a governor or parole board. In jails, for the postadjudication population, the process is less complicated. For the preadjudication population, the jail needs only to appeal to a judge. Regardless of the motivation for releasing terminally ill patients, such releases effectively reduce the number of deaths that are attributable to events that occurred during incarceration.
Incarcerated individuals may be transported to a hospital in the community because of a serious medical need that develops or is exacerbated during detention and later die at the hospital. During their tenure in the hospital, the individual typically remains in the custody of the detention authority. Occasionally, detention authorities release individuals from custody before deaths occur. Possible drivers include (1) the individual, typically someone serving a post-trial sentence, is released under a state or federal compassionate release or parole program; (2) the detention authority, typically a jail holding individuals pretrial, petitions the prosecutor or court to drop charges or release the individual on their own recognizance to shift the burden for payment of hospital costs to whomever would be responsible if the individual were not incarcerated; and (3) the same scenario, but the
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11 Presentation to the committee, Andrea Armstrong, Dr. Norman C. Francis Distinguished Professor of Law, Loyola University New Orleans, April 2, 2024.
impetus for release is to avoid the need to report the death to state and federal authorities as a death in custody.12
Mission
The primary mission of carceral facilities is public safety, not health care. Although that does not mean that carceral administrators can ignore the importance of health care, when the primary mission conflicts with a health care need, health care may suffer.13 An example of this tension is illustrated by the use of solitary confinement. To protect the safety of an incarcerated individual, staff, or other residents, or as punishment for misbehavior, individuals may be placed in solitary confinement. As discussed earlier in this chapter, it is well established that solitary confinement has a deleterious effect on mental health and access to care, and this sometimes leads to fatal outcomes (Brinkley-Rubinstein et al., 2019; Haney, 2018; Lobel and Akil, 2018).
Carceral health care providers must balance patient care against security requirements (see Box 4-3). For example, ambulances may be required to stop at the security gates of a carceral complex, which delays medical attention. As another example, health care professionals may be asked to release health records for forensic purposes in contravention of a patient’s interests (Shalit and Lewin, 2004).
Some correctional administrators restrict the clinical use of Food and Drug Administration–designated controlled substances to avoid risks to facility safety from drug diversion. For controlled substances used to manage opioid use disorder (i.e., buprenorphine and methadone), restrictions may be due to philosophical opposition to medication treatment for opioid use disorder (an aversion to what is erroneously seen as replacing one addiction with another) or lack of funds for such medications or staff to administer them. Such restrictions may severely impact patient care and safety. For example, a failure to provide narcotic analgesics when maximum dosages of nonnarcotic analgesics are insufficient to control postoperative pain leads to untreated pain. Failure to provide buprenorphine or methadone when indicated to treat opioid use disorder increases the risk of death from inadequately managed withdrawal or overdose.
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12 From a public health perspective, reporting such deaths to data-collecting authorities as deaths in custody has public health value. If the condition that led to the hospitalization and death began (or was exacerbated) in the carceral facility, counting and examining the circumstances of the death can provide information that contributes to a future reduction in the numbers of in-custody deaths.
13 Corrections officials and carceral health care providers, while serving the same government, have “different and often conflicting interests. The…administration’s main task is safety and security; the health authority’s is health care. As long as health care professionals working in [carceral facilities] are employed by the [facility] administration, they are vulnerable to pressures to serve…purposes other than patient care” (Pont, Stöver, and Wolff, 2012).
BOX 4-3
Responding to Medical Emergencies in Carceral Facilities
When there is a medical emergency in a carceral facility (e.g., a life-threatening cardiac or respiratory event), an alert is broadcast. First responders are usually corrections officers, who typically have training in basic lifesaving procedures (e.g., cardiopulmonary resuscitation [CPR], using automated external defibrillators). Unless a “do not resuscitate” order is in place, these first responders perform CPR and conduct other lifesaving measures.
Medical staff may not be permitted to approach an individual in distress until the scene is secure (e.g., corrections officers may have deemed it unsafe to enter an area because there is an ongoing assault or other threat to safety).
Depending on the nature of an emergency, 911 may be called to connect with emergency medical services (EMS). Critically, EMS response times are dependent on proximity of the service to the facility.
Lifesaving measures are typically performed until EMS arrives. On rare occasions, carceral medical staff may pronounce a death inside a facility but try to avoid this by, for example, continuing CPR until EMS can assume care and ultimately pronounce death at a medical facility. Regardless of the circumstances, decisions to cease life-sustaining medical procedures in a carceral facility can be fraught with complex legal, ethical, and medical considerations.
If a pronouncement of death happens inside a facility, the site becomes a crime scene. In such a case medical records would be locked, and personnel would be held for interviews. A Critical Incident Stress Management intervention (a protocol developed specifically to assist those dealing with traumatic events) might also be conducted.
Oversight
There is no national, uniform system of oversight for health care delivery in carceral settings. The primary system of oversight for delivery of community health care using a national standard is accreditation by the Joint Commission (formerly the Joint Commission on Accreditation of Health Care Organizations); this is driven by a requirement that hospitals and many other health care operations must be accredited to receive Medicare and Medicaid reimbursement. As these payors do not pay for services provided in a correctional setting, this mechanism for accreditation for carceral facilities is lacking.14 As a result, fewer than half of all carceral
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14 For Medicaid, the exclusion—the Medicaid Inmate Exclusion Policy—is articulated in the Social Security Act of 1965. For Medicare, the exclusion flows from federal regulation (42 C.F.R. § 411.4). Despite the Medicaid Inmate Exclusion Policy, 18 states have been granted waivers to provide Medicaid treatment to those who are close to release, under a demonstration project.
Where deaths appear to be suicides, a psychological autopsy may be performed. Such autopsies are led by a behavioral health specialist for the purpose of establishing a history from the day of an individual’s arrival into the carceral system until their date of death in order to understand what was in the mind of that individual and what led to suicide.
In the event of an in-custody death, corrections officers are usually the first witnesses. They report the death to the shift commander, and a notifications process is initiated. Family members are typically notified of a death by the senior facility administrator.
A death/mortality log is maintained by medical staff that lists the type of death, whether an autopsy was performed, toxicological information, and dates of medical reviews. If a facility has National Commission on Correctional Health Care accreditation, reviews are required in certain timeframes (usually within 30 days). If an autopsy or pathology or toxicology report isn’t received within the specified timeframe, mortality reviews are amended when the information becomes available. While facility medical staff do not typically attend autopsies, their knowledge of the case could provide value to the forensic pathologist making determinations of cause and manner of death.
Separately, EMS keep “run reports.” These reports document incidents and patient care provided by EMS personnel. The information in the reports can provide valuable information for subsequent mortality reviews.
A clinical mortality review (a process by which medical and other disciplinary experts review the circumstances of an individual death to explore root causes and identify interventions to prevent future deaths) may also be conducted.
SOURCE: Presentation to the committee, Johnny Wu, Executive Vice President and Chief Clinical Officer, Centurion Health, February 4, 2025.
facilities are accredited by either of the two entities that accredit using national standards: the National Commission on Correctional Health Care (NCCHC) and American Correctional Association (ACA).15
Federal organizations—such as the National Institute of Corrections, Bureau of Justice Assistance, and Centers for Disease Control and Prevention (CDC)—publish guidance for limited aspects of correctional health care, but these are crafted as guidance, not standards, and they are not accompanied by any enforcement mechanism.
Even when facilities are accredited, the scope of the standards is limited. The NCCHC and ACA set national standards and offer accreditation to jails and prisons for health care services. However, their standards, as do
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15 There are no reliable counts of the number of carceral facilities that are accredited because neither of these entities publishes that information. However, a recent randomized study of health care accreditation in 44 U.S. jails suggests “that accreditation improves coordination between health and custody staff” and “improves quality standards and reduces mortality among the incarcerated” (Alsan and Yang, 2025, p. 2).
state-specific standards, focus heavily on structural elements (e.g., whether the facility has policies addressing various operational activities) and basic processes of care (e.g., whether procedures were performed and performed within acceptable periods of time). The standards do not comprehensively address whether the structural elements are appropriate (e.g., a facility could be accredited because it has a policy on a given activity, even if the policy is poorly conceived) or whether the processes of care were performed in a clinically appropriate manner. About half of states have some type of standards for jail and prison health care, but, like those of the national organizations, these standards are disparate and tend to focus on structural elements and processes, not outcomes (Deitch, 2020).
Finally, because they have different missions, different types of carceral facilities present different health care challenges. Prisons tend to hold individuals for longer time periods and are typically in a better position to address long-term health care needs. Jails, on the other hand, typically hold individuals awaiting trial or serving short sentences, and they have high turnover rates. The transitory nature of jail populations complicates the delivery of consistent health care services, as many detainees stay only briefly before being released or transferred to other facilities. Consequently, chronic disease management, mental health services, and substance abuse treatment can be difficult to address (Rosen, 2023). Further, entry into, release from, and transfers between facilities can disrupt ongoing treatment plans. Medical records are not always adequately maintained or transferred, which can cause discontinuity of care.
If properly supported, the MLDI system can provide information on causes of death that can support quality control oversight for care delivery within the carceral setting with potential benefits that extend to workplaces, manufacturing, nursing homes, and even hospitals.
USE OF FORCE AND DEATH IN CUSTODY
While taking a person into custody or to maintain control in carceral settings, law enforcement and corrections officers may use force or forms of restraint that, under certain circumstances, can lead to a person’s death.16
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16 Use of force in carceral facilities is also important, as deaths in custody can result from the use of force by corrections officers or other carceral staff. Deaths resulting from the use of force by such individuals are separate from the use of force by one incarcerated individual against another that causes death. The available data about in-custody deaths are limited and incomplete for the reasons set forth elsewhere in this report (see, in particular, Chapter 3), but according to BJS (2021d), “homicide was the cause of 2% of state and nearly 3% of federal prison deaths. There were 120 homicides of state prisoners during 2018, including homicides committed by other prisoners, incidental to the use of force by staff, and resulting from injuries sustained prior to incarceration” (p. 2).
As stated in Chapter 3, the CDC’s National Violent Death Reporting System collects data on violent deaths, including homicides, suicides, and deaths where individuals are killed by law enforcement acting in the line of duty.17 This information is collected from death certificates, coroner/medical examiner reports, and law enforcement reports, and then entered into an anonymous database. Collected data elements provide valuable information about violent deaths, but they do not indicate whether a death occurred while a decedent was in custody (except, for instance, in cases where deaths were caused by law enforcement acting in the line of duty).
Certain types of restraint (and other measures employed by law enforcement to maintain control over an individual) can contribute to in-custody deaths. Police department policies typically call for the use of handcuffs and, if necessary, leg restraints to control individuals who pose a risk (Law Enforcement Policy Center, 2019). When dealing with individuals who may be intoxicated or experiencing a mental health crisis, police may employ other restraint maneuvers to achieve control, based on level of agitation, aggression, or unpredictable behavior (NIJ, 2009; see Box 4-4).
Within the continuum of force, law enforcement professionals are expected to apply restraint techniques with the aim of minimizing harm to both the individual and the officers involved (with an emphasis on using the least amount of force necessary to safely control the situation) (American Law Institute, 2025; Bollard et al., 2018). Nevertheless, exertion against restraint alters the body’s ability to respond normally. When an individual exerts themselves, their body produces lactic acid. A key mechanism for normalizing the blood’s acid level is rapid deep breathing (which expels carbon dioxide, a compound that contributes to the acid level in the blood). If an individual is restrained to the point that they cannot take deep breaths, the individual may quickly develop serious or potentially life-threatening levels of acidosis, which weakens the heart’s contractions and damages vital organs. While an otherwise healthy individual may be able to tolerate physiologic stress for a longer period of time, the presence of substances in the blood that increase physiologic stress (e.g., stimulants) and/or co-morbidities, such as heart or lung disease, reduces the body’s tolerance to stress; these can result in the individual succumbing to restraint in a much shorter amount of time.
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17 According to BJS (2024a), in fiscal year 2022, “homicides accounted for the largest portion (41%) of [federal] arrest-related deaths, followed by accidents (28%) and suicides (23%). In arrest-related deaths, 98% of decedents were male, 75% were white, and 53% were ages 25 to 44. In 55% of arrest-related deaths, law enforcement officers were serving a warrant when they made initial contact with the decedent. A violent offense was the most serious offense allegedly committed by decedents in 50% of arrest-related deaths. Decedents attempted to injure law enforcement officers in 35% of arrest-related deaths and discharged a firearm in 38%. Law enforcement officers discharged their firearms in 43% of arrest-related deaths” (p. 1).
BOX 4-4
The Restraint of Individuals During Encounters with Law Enforcement and Corrections Officers
Techniques used to control individuals in custody who may pose a risk to themselves or others include the following:
- Verbal de-escalation: Attempting to calm the individual through communication, which may help avoid physical confrontation (Rho et al., 2023).
- Physical restraints: Employing controlled physical holds, such as arm locks or wrist holds, to restrain without causing injury. These might include techniques such as an “escort hold,” where a law enforcement officer controls the arm and applies pressure to maintain compliance.
- Handcuffs and flex cuffs: Using handcuffs or plastic flex cuffs to restrict the individual’s movement, typically behind the back to prevent use of the hands as weapons or tools for escape.
- Leg restraints: In some cases, leg restraints may be used to control kicking or attempts to run. These are applied to immobilize the legs while maintaining a seated or prone position. They can also be attached to waist chains to further reduce movement.
- Body weight restraint: Law enforcement officers may use their body weight to pin an individual down temporarily, usually positioning the individual face-down or on the side to prevent thrashing or further aggression.
- Taser or conducted electrical weapons: In situations where the individual is highly agitated or poses a significant threat, a taser may be used to subdue an individual temporarily. Tasers are usually used as a last resort when verbal commands and physical restraints are ineffective.
- Spit hoods or masks: To prevent spitting or biting, law enforcement officers might use spit hoods, which are fabric hoods placed over the individual’s head. It is critical to employ spit hoods so that breathing is not obstructed, especially when an individual is under the influence of drugs that may affect respiratory function (Duret, 2024).
Emergency medical services (EMS) and law enforcement
frequently work as a team in encounters with individuals experiencing acute behavioral emergencies manifesting with severe agitation and aggression . . . . Optimal management is a rehearsed, coordinated effort by law enforcement and EMS providing the necessary interventions to address behaviors that endanger the patient, the responders, and the public. (Levy et al., 2024, p. 1058)
In early 2023, the National Association of EMS Physicians, the International Association of Fire Chiefs, and the International Association of Chiefs of Police convened a group of representatives to develop a consensus
statement to “provide guidance and direction in the shared responsibility of managing and caring for a person displaying behavioral instability with irrational, agitated, and/or violent behavior” (Levy et al., 2024, p. 1058).18 According to the final statement, for behavioral emergencies “an initial assessment of the scene must be performed, typically by” law enforcement. “During this scene size-up, observations include the types of behavior displayed by an individual, the presence of physical injuries, and the involvement of any weapons. Through these observations, officers may determine overall scene safety prior to on-scene EMS arrival.” The statement recommends that “all emergency personnel should have baseline training in de-escalation techniques” and that “open, two-way communication with patients and” law enforcement “be established early by EMS whenever
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18 The Police Executive Research Forum (2024) recently released 15 principles “for police on how to handle situations that may necessitate restraint but could also pose a heightened risk to the individual being restrained (p. 1). The principles are
- Identify warning signs of a medical-behavioral emergency—Police should recognize these signs and treat individuals as patients in need of medical care.
- Plan and develop protocols for a coordinated medical-behavioral emergency response—Stakeholders must collaborate on training and protocols.
- ICAT (Integrating Communications, Assessment, and Tactics) principles apply to medical-behavioral emergencies—Use the Critical Decision-Making Model and principles of time, distance, and cover.
- De-escalate wherever possible, but at a minimum—don’t escalate—Avoid actions that worsen the situation even if formal de-escalation is not fully possible.
- Evaluate the need to restrain immediately—If no immediate risk exists, hold off on restraint until EMS arrives or is nearby.
- Multiple Electronic Control Weapon (ECW) applications may increase the risks associated with restraint—Fewer applications should be prioritized and communicated to EMS.
- A supervisor or other leader needs to take charge—One person should manage the dynamics of a medical-behavioral emergency.
- Designate a Patient Safety Officer—Assign someone specifically to monitor the subject’s breathing and consciousness.
- Prone restraint carries potential risks and should be limited—Use prone positioning judiciously due to associated dangers.
- Not following directions does not always mean willful non-compliance—Understand that non-compliance may stem from confusion, medical distress, or other factors.
- The goal is control, NOT complete immobilization—Containing the person—not total stillness—is sufficient and safer.
- The ability to speak does not mean a person can breathe—Just because someone is verbally responsive doesn’t guarantee they’re not in physiological distress.
- On-scene coordination and collaboration between EMS and law enforcement is crucial during MBEs—Seamless teamwork on-site is essential.
- Keep emotions in check and be ready to step up and step in—Officers must maintain composure and be prepared to intervene if needed.
- Commit to learning from every incident—Review and integrate lessons from each event to improve future responses.
possible.” “While EMS can deliver advanced clinical care,” the statement-authoring organizations strongly encouraged that law enforcement officers receive recurrent training in basic lifesaving care; the group noted, however, that EMS “has a duty to evaluate and treat all patients in a timely fashion” (Levy et al., 2024, p. 1058).
The statement also notes that, while
individuals may display variable degrees of anxiety, agitation, combativeness, or extreme hostility requiring physical restraint by [law enforcement] officers and/or EMS . . . at the earliest possible time, the patient should be placed in the safest possible position. . . . In situations not responsive to de-escalation and/or physical restraint, EMS may consider pharmacologic management when the patient appears to be exhibiting a dangerous metabolic burden from the magnitude and duration of a continued struggle. A decision to utilize pharmacologic management shall be made solely by EMS based upon their independent patient assessment and in strict accordance with EMS protocols and medical director oversight. At the earliest practical time, all patients receiving this type of therapy should have monitoring of heart rhythm, blood pressure, oxygen saturation and end-tidal CO2 by EMS clinicians trained to recognize and treat potential side effects of the administered agent. . . . Any physical restraint device used must allow for rapid removal if the patient’s airway, breathing, or circulation becomes compromised. Rigid restraints, such as handcuffs, should not be used by EMS providers. If the patient is handcuffed by law enforcement officers, consideration should be made to transition to the least restrictive restraints that are safe for the patient and responders. . . . Patients must not be restrained in a position with hands and feet tied together behind their back or restrained with techniques that compromise the airway or constrict the neck or chest. During transport on a stretcher or other transport device, patients must not be restrained in a prone position nor under backboards or mattresses. (Levy et al., 2024, p. 1061)
The ability of law enforcement and correctional officers to differentiate between violent situations and those that result from mental health episodes is critical for reducing deaths in custody (see Box 4-5). Further, adopting good policing practices, such as refraining from high-speed chases for trivial offenses and the use of body and squad car cameras, can circumvent the types of escalation that can lead to needless death.
BOX 4-5
Colonie, New York: A Case Study of a Restraint Technique
While multiple approaches may be taken to restrain an agitated individual, law enforcement officers and emergency medical services (EMS) personnel in Colonie, New York, use a medical backboard to restrain agitated persons (Gerace and Dailey, 2023). In correspondence to the committee, Colonie Police Department Chief James J. Gerace recommended that “police leaders and trainers should teach their officers the concept that ‘struggle against restraints = a medical evaluation’” (i.e., that when an agitated individual struggles against restraints, they should be medically evaluated). “Colonie Police teaches these concepts through a primed recognition decision-making process[;] when a subject or suspect struggles after being restrained, this should be considered an irrational behavior that necessitates a medical intervention.” “Police leaders must provide their staff with a method of restraint, concrete guidelines, and training on how to get a subject that has struggled against restraints to a hospital.”a
According to Gerace, the backboard technique used by Colonie Police is “a way,” not “the way.”b Nevertheless, if medical intervention becomes “necessary, a patient secured to a backboard is already in an ideal position to receive it. There is no ‘frantic and chaotic toil’ to remove handcuffs when seconds count” and “a backboard provides a firm, flat surface if CPR or intubation is needed. Further, the positioning of the patient’s arms allows for rapid IV administration.” “If a hyperactive patient goes into cardiac arrest, EMS providers must have absolute access to the individual to help prevent a fatal incident.” Further, “transferring an arrestee at a hospital is fraught with potential injury to the subject, first responders, and hospital personnel. The goal in cases where people are resistant, assaultive, or otherwise difficult to manage is to move them from a narrow EMS stretcher to a wider hospital gurney.” “Traditionally, handling a handcuffed individual who is agitated or uncooperative means dragging or lifting them and potentially landing them on their wrists, causing injury. All lifting and moving points—arms, legs, and handcuffs—are on the patient” (Gerace and Dailey, 2023).
“When a patient is restrained to a backboard, officers and/or medical staff can simply lift the board and move it to the hospital stretcher. This prevents an uncontrolled handcuff or limb that could injure officers or hospital personnel. Handcuffs can then be exchanged for hospital hard restraints as ordered by the medical staff” (Gerace and Dailey, 2023).
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a James J. Gerace, correspondence dated January 20, 2025.
b James J. Gerace, correspondence dated January 20, 2025.
CONCLUSIONS
Conclusion 4-1: Lack of training for law enforcement and various factors at play in carceral settings, including a lack of consequential, mandatory standards for high-quality care, place the in-custody population at a heightened risk of death.
Conclusion 4-2: Individuals in custody have a higher prevalence of health conditions, a higher risk of all-cause mortality, and a higher risk of overdose mortality (including after release) than the general population.
Conclusion 4-3: Many in-custody deaths (suicides, overdoses, and homicides) are preventable, but such deaths are not routinely reviewed and may be undercounted and/or misclassified.
Conclusion 4-4: Incarcerated individuals too often receive inadequate health care for their medical needs, increasing the risk of otherwise-preventable deaths in custody.
Conclusion 4-5: Deaths in custody due to withdrawal from opioids and alcohol are not reported in national statistics. This hampers the ability to quantify the extent of such deaths and take remedial action.
Conclusion 4-6: Law enforcement and EMS training and collaboration are critical for reducing physical harm to (and deaths of) agitated individuals.
Conclusion 4-7: Information about deaths in custody in carceral settings can be particularly limited because of issues related to access to facilities, lack of mandatory reporting requirements, lack of access to medical records (which becomes more challenging when services are administered by private health care providers), and lack of cooperation from carceral staff, law enforcement, and medical personnel. Lack of information inhibits the ability of medical examiners and other MLDI professionals to make sound determinations of cause and manner of death for in-custody deaths.
Conclusion 4-8: Rigorous medicolegal death investigations provide data that can be used to improve the quality of care in the carceral system. Medicolegal death investigations of deaths in custody would benefit from efforts to improve transparency and increase access to information collected by carceral facilities. Mortality reviews with root cause analysis can elucidate inadequacies in carceral health care services.
