Report 2016-131 Recommendation 23 Responses

Report 2016-131: California Department of Corrections and Rehabilitation: It Must Increase Its Efforts to Prevent and Respond to Inmate Suicides (Release Date: August 2017)

Recommendation #23 To: Corrections and Rehabilitation, Department of

In an effort to prevent future inmate suicide attempts, Corrections should implement its plan to review attempts with the same level of scrutiny that it uses during its suicide reviews. Corrections should require each prison's suicide prevention team to identify for review at least one suicide attempt per year that occurred at its prison. To ensure that the reviews include critical and unbiased feedback, Corrections should either conduct these reviews itself or require the prisons to review each other. These reviews should start in September 2017 and follow the same timelines as the suicide reviews, with the timeline beginning once the team identifies a suicide attempt for review.

1-Year Agency Response

CDCR uses an aggregate Root Cause Analysis (RCA) process, supplemented with an additional mental health report that addresses requirements established by NCCHC and the American Association of Suicidology (the standards currently utilized on suicide case reviews). These RCA's are to be performed every six months. This requirement is contained in the SPRFIT enhancements. Training was held in January 2018.

California State Auditor's Assessment of 1-Year Status: Fully Implemented

6-Month Agency Response

CDCR will use an aggregate Root Cause Analysis process, supplemented with an additional mental health report that addresses requirements established by NCCHC and the American Association of Suicidology (the standards currently utilized on suicide case reviews). This requirement is contained in the SPRFIT enhancements. Training was held in January 2018.

A copy of the new audit item and results will be provided once complete.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

CDCR is exploring using a modified Root Cause Analysis process if it can be made applicable, supplemented with an additional mental health report that addresses requirements established by NCCHC and the American Association of Suicidology (the standards currently utilized on suicide case reviews). This requirement will be contained in the SPRFIT enhancements and will be audited.

A copy of the new audit item and results will be provided once complete.

California State Auditor's Assessment of 60-Day Status: Pending

All Recommendations in 2016-131

Agency responses received are posted verbatim.