Twenty years ago, a high-profile inmate suicide in Massachusetts made national news, shined a spotlight on a state crisis, and prompted calls for reform on Beacon Hill.
In the two decades since, Massachusetts has made strides to improve mental health care and deter suicides in prison, but the rate of self-inflicted inmate deaths in the state remains among the highest in the country.
The death of former Patriots star Aaron Hernandez on Wednesday marked the 65th reported suicide in the state’s prisons since John C. Salvi III was found beneath his cot in a Walpole prison cell in late 1996, a plastic trash-can liner secured around his head. He had been convicted of opening fire inside two Brookline abortion clinics in 1994, killing two and wounding five others.
After Salvi’s high-profile death, the state made cell-design improvements and conducted more frequent screenings of inmates, even those not considered to be a suicide risk, such as Hernandez, who was part of the general inmate population at the state’s maximum-security Souza-Baranowski Correctional Center in Shirley.
But investments in “suicide resistant” design have focused primarily on housing for inmates already identified as suicidal or placed on mental-health watch, not those in general population cells. And Hernandez’s reported method — hanging himself by a sheet secured from a window, apparently just a few feet off the ground — appeared to match a previous inmate suicide at Souza-Baranowski in October 2005.
“I’m not sure how that happened or how that could happen, but . . . it’s not the first time,” said James Pingeon, litigation director for Prisoners’ Legal Services of Massachusetts and a longtime advocate for poor and mentally ill inmates. Even design changes to make prison suicide far more difficult may not prevent them altogether, he said. “People tend to find a way.”
Years ago, Salvi’s suicide shook the state, Pingeon said, because he seemed so clearly mentally unwell to most observers, if not to prosecutors and the jury who convicted him. Salvi, who had earlier attempted suicide while awaiting trial, was described by defense witnesses as a paranoid schizophrenic prone to delusional rants about a Masonic conspiracy against Roman Catholics.
He was not ruled legally insane, and when he was convicted and sent to prison, he did not receive mental health treatment and was not placed on suicide watch, according to his family and advocates.
Despite increased scrutiny, eight more inmates killed themselves in Massachusetts the following year, giving the state a suicide rate in 1997 of 74 per year per 100,000 inmates, or more than 3½ times the national average that year.
That prompted lawmakers to switch mental health contractors and hire more providers in the late 1990s. Though the suicide rate dropped over the next few years, budget issues and case-by-case lapses persisted, and in the mid-2000s the rate surged again, as 16 inmates killed themselves between 2005 and 2007.
Responding to inmate lawsuits and a Globe Spotlight series, the state hired a leading national consultant on prison suicide-prevention, Lindsay Hayes, who spent months visiting prisons and interviewing employees and inmates. In 2007, Hayes issued a 66-page report recommending changes to a host of areas, including staff training, screening, and facilities.
The state implemented some of them, such as requiring prison employees to take eight hours of suicide-prevention training their first year and at least two hours of refresher training annually, but slowed the reforms amid the ensuing fiscal crisis.
In 2009 and 2010, the rate spiked again — and the state rehired Hayes, who issued a second sweeping report in 2011.
Both reports focused primarily on deterring suicides among inmates already considered at-risk, such as eliminating ventilation grates with holes that could anchor a makeshift noose.
But in the 2011 report, Hayes also noted a persistent problem with follow-up screening of even inmates not previously deemed to be at risk.
The Massachusetts Department of Correction “has continued to struggle (as most state correctional agencies do throughout the country) with realistically being able to re-screen all inmates following their return from a court proceeding,” Hayes wrote.
John Beland, a former Souza-Baranowski mental health clinician who now works in private practice, told the Globe Wednesday that the Shirley prison adopted that change, meaning Hernandez most likely spoke with a mental health clinician each night during his recent trial before being allowed back into his cell. (The Department of Correction declined to answer follow-up questions Wednesday beyond the initial statement about Hernandez’s death.)
Beland said the typical windows at Souza-Baranowski still have an anti-escape bar across the inside, and that, though difficult, a determined inmate could force a sheet around that bar and lower himself until it tightens enough around his neck to choke off air.
Hayes, the consultant, said by e-mail that he expected the state and its prison mental health provider to conduct a comprehensive review into Hernandez’s death and whether it was preventable.
Data from the federal Bureau of Justice Statistics show that there were 32 suicides per 100,000 state and federal prisoners in Massachusetts between 2001 and 2014 — the fourth-highest rate in the country.
Nationally, about 250 suicides occur in state and federal prisons each year, a rate of about 20 per 100,000 inmates, while about 400 occur in county jails, where the rate is 2½ times higher. Both are far higher than the rate among people who are not incarcerated, with about 13 suicides per 100,000 annually, he said.
Even with improvement, the Massachusetts prison suicide rate most years eclipses the nation’s. State Senator Jamie Eldridge, an Acton Democrat whose district includes Souza-Baranowski and a neighboring medium security prison, MCI-Shirley, has filed legislation calling for a commission to study the causes of suicides by both prisoners and correctional officers.
“The fact that the suicide rate by correctional officers and prisoners is so high speaks to the toxic culture in our prisons,” he said.
If you or someone you know is having thoughts of suicide, call the National Suicide Prevention Lifeline at 1-800-273-8255.Mark Arsenault, Maria Cramer, and Matt Rocheleau of the Globe staff contributed to this report. Eric Moskowitz can be reached at firstname.lastname@example.org.