By Terrell J. Marshall
Millions of people cycle through American prisons and jails every year. In 2025, The Marshall Project exposed flaws in the way the government tracked more than 21,000 people in custody who never made it home.
“Incarcerated people die of medical neglect. They die because guards beat them or because they get into fights with each other. They get sick or succumb to terminal illness,” wrote Ilica Mahajan in an article for The Marshall Project.
Congress passed the Death in Custody Reporting Act more than 20 years ago. The intention was to generate a record of everyone who dies while in law enforcement custody.
The Marshall Project attained combined statistics for in-custody deaths from the Justice Department’s website, which accidentally made the data accessible to the public on the internet.
The evidence gathered from the database between Oct. 1, 2019 and Sept. 30, 2023 showed that the cause of death for more than a third of cases could not be determined due to lack of information, which was cause for concern.
Analysis revealed many of the Death in Custody Reports were riddled with errors. Hundreds of deaths were missing, and most of the details describing how individuals died did not meet the government’s own minimum quality standards.
“How can we decrease preventable death if we don’t understand who’s dying or why they’re dying?” asked psychologist Sharen Barboza, who has worked in various prison’s for more than two decades. She felt much of the information from previous reports of this type was more accurate, and the newer government data is not particularly helpful because of lack of detail.
When asked, representatives for the Department of Justice did not provide on-the-record comments on this story. The DOJ does, however, review the cause of death listed in Death in Custody reports provided to each state and according to their website, “acknowledges ongoing reporting gaps and challenges that may affect the accuracy and completeness of…[in-custody death] reporting.”
Of the 21,675 incarcerated deaths noted in the data, insufficient evidence in the cause of death was labeled as “suicide” or death from “natural causes” without details or justification.
In the 60 percent of cases where there was enough information to determine cause of death, the most common was related to heart conditions, followed by cancer, and then respiratory illnesses.
The Marshall Project uncovered that the leading cause for younger incarcerated people was suicide, followed by drug overdoses, and stated that, “for incarcerated people under the age of 55, just under half of the deaths we could identify were from largely preventable causes…,” noted the article.
The procedure on how to report on in-custody deaths by each state was inconsistent and disorganized.
Typically, upon the death of an incarcerated person, a coroner or medical examiner will determine the cause. The report includes standard autopsy and toxicology tests, along with interviews of medical staff, guards, and other witnesses as to how and why a person died.
The Bureau of Justice Assistance’s job is to administer federal in-custody death tracking guidelines, which include what type of data to collect and how to classify death.
Even though this department has the power to penalize states who do not comply with the BJA guidelines, this agency has never penalized any state for incomplete or sloppy reporting, noted the article.
“Last year Lelipe Portillo died of a heart attack right in the South Block rotunda,” said San Quentin Rehabilitation Center resident Tony Chavez. “After the guards pushed the alarm, Felipe just sat there suffering for 20 minutes, and by the time the nurses finally showed up, he was a goner.”
Chavez added that the facility’s nursing station was only 40 feet away from the incident, and neither the medical staff nor the officers started lifesaving measures soon enough to save his life.
Dr. Barboza asked: “Do we, as a country, care about those we incarcerate? … Do we care if they’re cared for? Do we care if they are dying? Do we care how they die? Are we interested in decreasing those deaths?”
“And the sad answer,” she said, “is no one’s all that interested in really understanding.”