Suicide in Prison: A Forensic Analysis of Sixteen Cases in Correctional Settings

Abstract

Background/Objectives: Suicide in prison is a significant medico-legal and public health concern, with rates several times higher than in the general population. Vulnerability is heightened by psychiatric disorders, substance use, and custodial stressors such as isolation, overcrowding, and restricted healthcare access. This study examines custodial suicides to identify diagnostic complexities, systemic shortcomings, and possible prevention strategies, including technological innovations. Methods: We conducted a retrospective forensic investigation of sixteen confirmed custodial suicides between 2022 and 2024. Each underwent a standardized protocol comprising crime scene inspection, complete autopsy, histopathology, toxicology, and review of prison medical and psychiatric records. Data on suicide methods, psychiatric comorbidities, and substance use were analyzed. Results: Hanging was the predominant method (12/16), displaying classical forensic signs such as pale, oblique ligature marks and petechial hemorrhages. Four cases involved acute intoxication, often with non-prescribed drugs. Psychiatric disorders were identified in 14 cases, including major depressive disorder, bipolar disorder, and substance use disorder. Toxicological analyses revealed both prescribed and illicit substances, highlighting unauthorized exchanges within facilities. Autopsy findings consistently excluded homicide or natural causes, confirming the vitality of lesions and the mechanism of death. Conclusions: Custodial suicides are strongly associated with untreated or inadequately managed psychiatric conditions, compounded by restrictive prison environments. Comprehensive forensic autopsies are essential for accurate cause-of-death determination and institutional accountability. Preventive strategies should combine psychiatric care, architectural modifications to reduce ligature points, and ethical integration of AI-based surveillance for early detection of suicidal behavior. A multidisciplinary, rights-based approach is crucial to reduce suicide rates and safeguard the dignity and life of incarcerated individuals.

1. Introduction

Suicide in custodial environments constitutes a significant public health crisis and one of the leading causes of death among the prison population globally [1]. Recent epidemiological data indicate that suicide rates among prisoners are several times higher than in the general population [2]. According to the World Health Organization (WHO) [3] and the International Centre for Prison Studies [4], in Europe, the prison suicide rate averages around 8.5 per 10,000 inmates per year, compared to approximately 1.3 per 10,000 in the general population. Countries such as France, Belgium, and Australia report some of the highest prison suicide rates worldwide [3]. The methods employed in custodial suicides are notably consistent across different regions. Hanging remains by far the most common method, accounting for over 70% of prison suicides, primarily due to the accessibility of materials such as bedsheets, belts, and clothing, and the availability of ligature points in cells [5]. Other methods, such as self-strangulation, drug overdose, or exsanguination through self-inflicted wounds, are much less frequent but represent significant diagnostic challenges [1,6].

Moreover, suicide is not the only cause of death in prison settings. Incarcerated individuals also face increased mortality from natural causes, often accelerated by inadequate access to medical care, as well as from violence, accidental deaths, and, in rare cases, undetected homicides [7]. The context of prison mortality thus presents a complex and multifactorial landscape requiring nuanced forensic evaluation. The prison environment itself—marked by severe restrictions, social isolation, overcrowding, and limited access to psychiatric support—acts as a potent catalyst for the worsening of psychiatric conditions and the emergence of acute psychological crises. Mental disorders such as major depressive disorder, bipolar disorder, psychotic disorders, and substance use disorders are disproportionately prevalent in incarcerated populations, often remaining underdiagnosed or poorly managed [8]. From a forensic perspective, determining the cause and manner of death in custodial settings is of paramount importance, not only to ensure justice and transparency in individual cases but also to uncover systemic shortcomings in the management of vulnerable populations. Comprehensive forensic investigations, including complete autopsies, histopathological examinations, and advanced toxicological analyses, remain indispensable tools for distinguishing between suicide, homicide, and accidental deaths within correctional facilities [9,10]. This study presents a retrospective forensic analysis of sixteen suicide cases occurring in prison, focusing on the integration of autopsy findings with clinical histories and circumstantial evidence. Beyond the medico-legal aspects, the study critically examines the systemic issues related to prison mental healthcare. It discusses innovative strategies—including the deployment of artificial intelligence technologies—aimed at enhancing suicide prevention [11]. Across Europe, suicide remains the leading cause of death in custody, with rates consistently higher than in the general population. According to the Council of Europe Annual Penal Statistics (SPACE I), the average suicide rate in European prisons has remained between 5 and 12 times higher than community levels, with hanging reported as the most frequent method of self-inflicted death. Comparative studies highlight significant heterogeneity: Scandinavian countries, where custodial models emphasize rehabilitation and social reintegration, report lower suicide rates, while Southern and Eastern European systems, often characterized by overcrowding, limited access to psychiatric care, and punitive regimes, show higher incidence of self-harm and suicide. Commonly identified risk factors include major depressive disorder, bipolar and psychotic illnesses, substance use disorders, social isolation, and exposure to solitary confinement. Despite this consolidated evidence, systematic forensic studies remain scarce. In particular, there is a paucity of Italian research that integrates autopsy, histological, and toxicological findings with clinical and custodial data to provide a comprehensive medico-legal reconstruction of custodial suicides. In Italy, prison healthcare is managed within the framework of the National Health Service, following the 2008 legislative reform (DPCM 1 April 2008) that transferred medical responsibility from the Ministry of Justice to the Ministry of Health. This integration was intended to guarantee equal standards of care between the prison and the community, particularly in the field of mental health. In practice, however, chronic structural issues persist. Italian prisons continue to face severe overcrowding, with occupancy rates frequently exceeding 110% of capacity according to Council of Europe reports, creating conditions of stress, reduced privacy, and difficulty in ensuring individualized psychiatric support. Staffing levels remain inadequate, with mental health teams often composed of a small number of psychiatrists and psychologists who must cover large and complex institutions, leading to fragmentation of care and limited continuity in follow-up.

Furthermore, although national protocols formally require suicide risk assessment at prison entry and during detention, their implementation is inconsistent across facilities, frequently depending on local resources, training, and the subjective initiative of custodial and health staff. This variability contributes to gaps in early detection of psychiatric vulnerability and in the timely adoption of preventive measures such as enhanced surveillance, allocation to observation units, or environmental modifications to reduce ligature points. In addition, the Italian prison system is marked by the widespread use of solitary confinement as a disciplinary measure, a practice repeatedly identified as a factor increasing psychological distress and suicide risk.

This systemic background—combining legislative intentions of healthcare equivalence with structural limitations of overcrowding, understaffing, and uneven psychiatric provision—is essential to interpret the vulnerabilities highlighted by our case series and to contextualize the shortcomings of mental health management within Italian custodial settings.

The present study aims to address this gap by analyzing the forensic, clinical, and custodial characteristics of suicides in an Italian prison population, and by evaluating how such integration can inform suicide prevention strategies.

2. Materials and Methods

2.1. Subjects

This retrospective study includes sixteen cases of custodial deaths classified as suicides, examined between 2022 and 2024. During this period, a dedicated database was developed for the systematic collection of judicial autopsy data at the Institute of Forensic Medicine of the University of Palermo. Out of a total of 254 autopsies performed, sixteen cases were selected for inclusion in the present study. Inclusion criteria were deaths of individuals in custodial settings (prison environment); deaths resulting from self-inflicted violent causes (e.g., hanging, self-inflicted trauma). While exclusion criteria included: deaths of incarcerated individuals from natural causes (e.g., myocardial infarction, infections). A fundamental step of the medico-legal investigation was the systematic assessment of potential factors that could challenge the suicidal nature of death. As part of a standardized approach, each case was evaluated for the vitality of lesions, the presence of suspicious injuries, and any unclear circumstances. The evaluation was conducted from the scene inspection through to histological and toxicological investigations, with the specific aim of identifying possible non-suicidal causes of death. In all cases, alternative hypotheses were carefully considered and subsequently excluded based on the available evidence, thereby confirming the classification of the events as suicides. Each case was anonymized and referred to as subject 1 through subject 16. All data derived from judicial autopsies were handled in an anonymized form, in accordance with the applicable Italian legislation (Legislative Decree 196/2003, art. 2-terdecies). To further minimize the residual risk of re-identification, individual ages were reported in 5-year ranges rather than as exact values, and non-essential narrative details that could function as quasi-identifiers were removed. No linkage with publicly available or media sources was performed. These measures ensured an appropriate balance between data protection and the preservation of analytical value.

2.2. Methods

For each case, a standardized investigative procedure was applied, beginning with the crime scene inspection. This phase enabled the forensic team to collect circumstantial evidence, documenting the cell’s conditions, the presence of ligature materials, and the body’s initial positioning. Subsequently, a comprehensive judicial autopsy was conducted by established forensic protocols. The external examination paid particular attention to the search for ligature marks, petechial hemorrhages, defensive injuries, or other signs suggestive of third-party involvement. The internal examination included the systematic dissection of the cervical structures to evaluate potential fractures of the hyoid bone or thyroid cartilage, pulmonary congestion, visceral stasis, and other signs typically associated with death by hanging or other violent mechanisms. In addition to macroscopic assessments, extensive histopathological investigations were performed. Tissue samples from vital organs, including the brain, lungs, heart, liver, and kidneys, were examined to confirm the antemortem nature of the lesions, identify potential comorbidities, and rule out pathological causes of death. Toxicological investigations were conducted on biological fluids, including blood and urine. These included first-level screening tests (for common drugs of abuse and prescribed medications) and second-level confirmatory tests, which used quantitative methodologies to precisely determine the presence and concentrations of pharmacological or illicit substances. Finally, all forensic data were integrated with the review of clinical and custodial records, including psychiatric evaluations, suicide risk assessments, and prison surveillance documentation, to achieve a comprehensive medico-legal reconstruction of each case. Psychiatric information was derived from the official medical files of the correctional facilities, compiled by qualified healthcare staff and, in particular, by psychiatrists who had followed the inmates throughout their detention. When available, diagnoses were reported according to DSM-5 or ICD-10 classifications; in the absence of formal coding, the descriptive clinical diagnoses recorded by the treating psychiatrists were transcribed.

3. Results

3.1. Demographic and Clinical Characteristics

The analyzed sample consisted of sixteen individuals aged between 25 and 55 years. Two subjects, out of sixteen, were female, and the other fourteen were male. Psychiatric comorbidities were identified in fourteen subjects. Among these, the majority (twelve inmates) had a documented diagnosis of major depressive disorder, while one case was diagnosed with bipolar disorder and another with a psychotic disorder. In addition, five subjects had a documented history of substance use, although without a formal psychiatric diagnosis of substance use disorder (SUD). This information was derived from the psychiatric anamnesis reported in the inmates’ medical records, as the entire health documentation from the correctional facilities was systematically reviewed during the preliminary phase of the study. Two further inmates, despite the absence of a formal psychiatric diagnosis, displayed behavioral instability, defined as repeated episodes of agitation, self-harming behavior, or aggressive conduct recorded in custodial or clinical notes, which were considered suggestive of underlying psychopathology.

3.2. Suicide Risk Assessments and Custodial Management

Suicide risk assessments and custodial management strategies were systematically reviewed in all cases. In nine subjects, a formal suicide risk assessment had been performed upon admission or during detention, while in the remaining seven the documentation was absent or incomplete. Among those assessed, five were classified as high risk and placed under enhanced surveillance measures, three were considered at moderate risk, and one at low risk. The most common management strategies included increased custodial observation, allocation to specialized observation units, and restriction of ligature points. At the time of death, two subjects were housed in isolation cells, four were under intensified observation, and the others were in ordinary prison wards. These findings highlight the variability in both the availability of standardized risk assessments and the implementation of consequent preventive measures. The custodial characteristics, the availability of suicide risk assessments, and the management measures adopted are summarized in

Table 1. Summary of suicide risk assessments and management.

Subject	Suicide Risk Assessment Available	Risk Level (If Assessed)	Management Measures Adopted	Location at Time of Death
1	Yes	High	Enhanced surveillance, reduced ligature pts	Ordinary ward
2	No	-	None documented	Ordinary ward
3	Yes	Moderate	Observation unit	Observation unit
4	Yes	High	Enhanced surveillance	Isolation cell
5	No	-	None documented	Ordinary ward
6	Yes	Low	Routine surveillance	Ordinary ward
7	No	-	None documented	Ordinary ward
8	Yes	High	Restriction of ligature points	Isolation cell
9	Yes	Moderate	Enhanced surveillance	Ordinary ward
10	No	-	None documented	Ordinary ward
11	Yes	High	Enhanced surveillance, restricted access	Observation unit
12	Yes	Moderate	Enhanced surveillance	Ordinary ward
13	No	-	None documented	Ordinary ward
14	Yes	High	Enhanced surveillance, observation unit	Observation unit
15	No	-	None documented	Ordinary ward
16	Yes	High	Restriction of ligature points	Ordinary ward

(Table 1).

3.3. Medico-Legal Findings

Twelve of sixteen subjects died by suicidal hanging. External examination in all twelve revealed the presence of pale, dry ligature marks located at the upper third of the neck, following an oblique and ascending trajectory, associated with the classical distribution of petechial hemorrhages on the conjunctivae and facial skin. There were no defensive wounds or signs of third-party intervention. Internally, nine cases exhibited cervical soft tissue hemorrhagic infiltration, while no fractures were observed in the hyoid bone or thyroid cartilage across all eleven instances. In all twelve cases, the thoracic organs consistently showed signs of pulmonary congestion and generalized visceral stasis, in line with typical asphyxial mechanisms. In two out of the twelve cases analyzed, a dual self-harm mechanism was identified. In one case, the individual inflicted a stab wound to the left lateral cervical region; in the second case, the individual ingested multiple razor blades and a pair of eyeglasses, with the fragments later recovered from the ileocecal valve during autopsy. A linear trajectory with sharp, well-defined margins and absence of underlying tissue bridges characterized the stab wound. Autopsy confirmed the sectioning of soft tissue but not major vascular structures. Notably, in both cases, no hesitation wounds or defensive injuries were observed. There were dry ligature marks located at the upper third of the neck. Histopathological examination in all cases confirmed the vitality of the observed injuries. Microscopic analysis highlighted hemorrhagic infiltration of the perivascular cervical tissues, alveolar edema, and hemorrhage within the pulmonary parenchyma. In one case, mild chronic inflammatory changes were detected in the liver, consistent with a history of substance use, while no acute or chronic myocardial pathology was identified. Toxicological investigations carried out in cases where death was not attributable to substance abuse (twelve out of sixteen cases) revealed the presence of benzodiazepines at therapeutic concentrations in eight cases, and in four other cases, traces of antidepressants compatible with prescribed medical treatments. In four of sixteen cases, the subjects were inmates with a documented history of substance abuse. They were found in severely compromised neurological conditions: one in a profound comatose state, another exhibiting progressive confusion and somnolence, ultimately culminating in death, and the other two subjects were found dead. Emergency interventions, including administration of Naloxone and oxygen therapy, were promptly initiated in all cases; however, the clinical outcomes diverged, with one subject surviving initially and undergoing prolonged hospitalization, while another died within a few hours, and two subjects died immediately. Toxicological screenings revealed the presence of psychoactive substances in all cases. In one instance, positivity for cannabinoids, methadone, and benzodiazepines was documented, whereas in the other, toxicological evidence indicated the ingestion of buprenorphine and diazepam. In two cases, phenobarbital and methadone were found above the therapeutic range (

Table 2. Summary table of toxicological findings in acute intoxication deaths.

Subject	Drug Founded	Prescribed Drugs	Non-Prescribed Drugs	Therapeutic Range
1	Cannabinoids, methadone, and benzodiazepines	Benzodiazepines	Methadone	Not methadone
2	Buprenorphine and benzodiazepine	Buprenorphine and benzodiazepine	No	No
3	Phenobarbital and methadone	Phenobarbital	Methadone	No
4	Phenobarbital and methadone	Methadone	Phenobarbital	No

). Autopsy findings showed marked similarities, presenting cerebral edema and systemic vascular congestion. Nevertheless, the neuropathological alterations were notably distinct: one case exhibited widespread ischemic lesions and chronic hypoxic brain injury consistent with prolonged survival in a vegetative state. At the same time, the other three displayed acute pulmonary congestion and petechial hemorrhages, indicative of rapid cardiopulmonary failure. Macroscopic examinations confirmed the presence of diffuse edema and congestion without evidence of recent traumatic injuries. In the case of extended survival, histological analyses highlighted significant rarefaction of the cerebral white matter and secondary organ damage attributable to sustained hypoxic conditions. Conversely, three acute death cases predominantly revealed pulmonary and cerebral congestion without chronic tissue alterations. Histological investigations demonstrate anoxic encephalopathy, multiorgan impairment, acute vascular congestion, and edema. In three cases, toxicological analyses revealed the presence of non-prescribed pharmaceuticals, indicative of unauthorized drug exchanges within the correctional setting (Table 2). In summary, the demographic features of the sample, the distribution of psychiatric comorbidities, and the documented histories of substance use, together with the causes and methods of death, are collectively reported in

Table 3. Summary of forensic findings with an overview of 16 cases detailing the cause of death, suicide methods, psychiatric history, and substance use.

Subject	Age	Sex	Cause of Death	Materials and Methods of Suicide	Psychiatric History	Psychiatric Disorder	Substance Use
1	30–35	M	Hanging	Bedsheet ligature	Yes	Major depressive disorder	No
2	25–30	M	Hanging	Clothing ligature	No	Behavioral instability	No
3	40–45	F	Hanging	Improvised rope	Yes	Major depressive disorder	No
4	35–40	M	Hanging	Bedsheet ligature	Yes	Major depressive disorder	No
5	35–40	M	Hanging	Bedsheet ligature	Yes	Major depressive disorder	No
6	30–35	M	Hanging	Fabric ligature	Yes	Major depressive disorder	No
7	45–50	M	Hanging	Wool fabric	Yes	Major depressive disorder	No
8	50–55	M	Acute intoxication	Drug ingestion	No	Behavioral instability	Yes
9	50–55	M	Hanging	Fabric ligature and stab wound	Yes	Major depressive disorder	No
10	40–45	M	Hanging	Bedsheet ligature	Yes	Major depressive disorder	No
11	30–35	M	Acute intoxication	Drug ingestion	Yes	Major depressive disorder	Yes
12	25–30	M	Acute intoxication	Drug ingestion	Yes	Major depressive disorder	Yes
13	45–50	M	Hanging	Bedsheet ligature and foreign body ingestion	Yes	Bipolar disorder	No
14	25–30	M	Hanging	Bedsheet ligature	Yes	Major depressive disorder	Yes
15	35–40	M	Hanging	Bedsheet ligature	Yes	Psychotic disorder	No
16	30–35	F	Acute intoxication	Drug ingestion	Yes	Major depressive disorder	Yes

, providing a comprehensive overview of the study population (Table 3).

4. Discussion

From a medico-legal perspective, custodial suicides present several significant challenges. These include distinguishing suicide from homicide or accidental death, especially in complex or ambiguous cases, and assessing whether systemic failures contributed to the fatal event [12,13,14]. The role of forensic autopsy is crucial in such contexts: meticulous documentation of external and internal findings, evaluation of the vitality of lesions, and exclusion of third-party involvement are fundamental steps in reaching an objective conclusion [10,15]. In our cases, autopsies allowed for the confirmation of typical hanging patterns, the identification of hemorrhagic infiltrations consistent with antemortem trauma, the confirmation of acute intoxications, and the exclusion of pathological conditions that could independently justify death. Histological examinations further supported the diagnosis, providing microscopic evidence of vitality. Toxicological analyses clarified the pharmacological background of each subject, excluding or confirming overdose or poisoning. Thus, comprehensive autopsies not only fulfilled a diagnostic role but also contributed to the broader understanding of prison suicides, supporting judicial authorities in evaluating the appropriateness of custodial care and surveillance protocols [16,17]. In an era where forensic investigations are increasingly questioned, thorough autopsy practices remain an indispensable tool to ensure transparency, justice, and the protection of human rights within custodial settings. The study of deaths in prison has highlighted the main critical issues in the management of inmates, particularly concerning the management of psychiatric disorders and the reduction in suicide risk [18,19]. Case-by-case analysis revealed that psychiatric disorders represent a critical vulnerability in custodial suicides. Some subjects suffering from major depressive disorder exemplified the high suicide risk associated with depressive symptoms exacerbated by isolation and restricted liberty. One subject with bipolar disorder highlighted how mood fluctuations, combined with the stressors of imprisonment, can result in sudden suicidal crises. Other cases illustrated how substance use disorders, often accompanied by impulsivity and emotional dysregulation, increase suicide risk when combined with withdrawal and institutional deprivation, particularly in subjects with a history of crimes against the family. Other cases demonstrated that even in the absence of a formal diagnosis, behavioral instability can conceal underlying psychopathology sufficient to lead to suicide. Managing psychiatric disorders in prison remains exceptionally difficult [20,21,22,23]. Overcrowded environments, limited access to mental health professionals, stigma associated with mental illness, and bureaucratic obstacles to continuous psychiatric monitoring severely undermine care quality [24,25,26,27,28,29,30]. Additionally, the prison regime itself—characterized by routine, restriction, lack of privacy, and sometimes overt violence—acts as a chronic psychological stressor, heightening psychiatric symptomatology [31,32,33,34]. The preferred method of suicide in prison—hanging—is a consequence of opportunity, lethality, and privacy. Hanging requires minimal materials, offers a high probability of death, and can be accomplished quickly, often without detection by surveillance staff [2,5,9,35]. This preference is documented extensively in the scientific literature, with rates exceeding 70% in various prison populations worldwide [36,37,38]. The lethality of hanging and the environmental ease with which it can be executed within custodial settings remain major challenges to prevention efforts. International comparisons reveal significant differences in suicide rates and prevention strategies [1,18,39,40,41]. Scandinavian countries, such as Norway and Sweden, adopt prison models focused on rehabilitation, dignity, and community reintegration, resulting in lower suicide rates. Conversely, more punitive systems, such as those prevalent in the U.S., report higher suicide rates, particularly in facilities practicing solitary confinement [42,43,44]. Isolation, in particular, has been identified as a major independent risk factor for suicide, with solitary confinement tripling the risk compared to general population incarceration [16,45]. Critical analysis suggests that restrictive prison conditions—lack of social interaction, sensory deprivation, and the perception of hopelessness—amplify psychiatric morbidity and suicidality [31]. Moreover, inadequate staff training in recognizing and managing psychiatric emergencies further exacerbates vulnerability. To reduce suicide risks, prisons must implement dynamic, interdisciplinary risk assessments with frequent reassessments. Embedding psychiatric professionals permanently within facilities, ensuring continuous care, and integrating mental health monitoring into daily operations are crucial steps [21,25]. Architectural redesigns to eliminate ligature points, control programs aimed at limiting the exchange of illicit substances and medications, as well as programs offering meaningful activities to counteract hopelessness and monotony, are proven preventive strategies [46,47]. Technological solutions, including behavioral analytics and AI-enhanced surveillance, should be cautiously evaluated for their capacity to predict risk without infringing on human rights [48,49]. Ultimately, protecting the mental health of prisoners must become as central a goal as maintaining security. Investment in mental health resources, de-stigmatization of psychiatric support, and humane prison environments are necessary to reduce suicide rates. In this context, the integration of artificial intelligence (AI) systems into prison surveillance may represent a promising strategy for suicide prevention [48,49]. AI-driven video monitoring platforms, capable of continuously analyzing inmates’ postures, micro-movements, and interaction patterns, can identify early warning signs of self-harming tendencies—such as unusual positioning near ligature points, prolonged inactivity during periods of expected activity, or sudden behavioral anomalies indicative of psychological distress. Pilot projects such as Falcon and Guardian AI are already being tested in correctional facilities, where real-time algorithms process high-resolution video streams, trigger alerts when detecting predefined high-risk behaviors, and enable immediate custodial intervention [11,50,51,52,53,54]. In some prototypes, these systems are also integrated with wearable devices (e.g., wristbands or biosensors) that monitor vital parameters such as heart rate variability, agitation levels, or sleep disruption, thereby enhancing the predictive capacity of surveillance networks.

Beyond video and biometric analysis, predictive algorithms incorporating multiple data sources—psychiatric histories, disciplinary records, behavioral monitoring, and custodial notes—could provide a dynamic, individualized stratification of suicide risk [55,56]. This multidimensional approach would allow for early identification of vulnerable inmates, timely adjustment of surveillance levels, and targeted allocation of preventive resources such as observation units or increased psychiatric support. In theory, AI could complement current static and subjective assessments by offering real-time, objective, and adaptive monitoring tools [57,58].

Nevertheless, the potential of these technologies must be carefully balanced against ethical, legal, and human rights considerations. The use of continuous monitoring raises concerns regarding privacy, proportionality of surveillance, data security, and the possibility of algorithmic bias leading to false positives or stigmatization of certain inmate groups. Moreover, excessive reliance on automated systems risks shifting the custodial model toward hyper-surveillance, thereby exacerbating the very psychological distress that such tools are designed to mitigate. For these reasons, the deployment of AI in correctional settings should be framed within strict legal safeguards, independent oversight, and transparent protocols, ensuring that technology serves as an adjunct rather than a substitute for human clinical judgment and custodial care. If implemented within a rights-based framework, AI systems may become valuable allies in suicide prevention strategies, fostering transparency, accountability, and ultimately safeguarding the dignity and life of incarcerated individuals [53,54,55,59,60,61].

5. Study Limitations

This study presents several limitations that must be acknowledged. First, the sample was relatively small and restricted to a single Italian jurisdiction, which limits the generalizability of the findings to other custodial contexts. Second, the retrospective design made the analysis dependent on the completeness and accuracy of available records, and in some cases, clinical or custodial documentation was fragmented or incomplete. Third, the assessment of psychiatric comorbidities relied on existing prison medical files and treating psychiatrists’ notes, without the possibility of standardized re-evaluation, which may have led to diagnostic variability. Furthermore, suicide risk assessment protocols were not consistently available for all inmates, reflecting institutional heterogeneity that may have influenced the interpretation of preventive strategies. Finally, although the data were anonymized and presented in aggregated form, the inherent sensitivity of custodial cases entails a residual theoretical risk of re-identification. These limitations highlight the need for larger, multicenter studies with standardized methodologies to provide more robust and generalizable evidence.

6. Conclusions

The analysis of sixteen custodial suicides confirmed the complex interplay between individual psychiatric vulnerability and the structural conditions of imprisonment. Most of the inmates presented with major depressive disorder or other psychiatric conditions, while in several cases a history of substance use emerged even in the absence of a formal diagnosis of substance use disorder [62,63]. The presence of behavioral instability in subjects without a psychiatric diagnosis highlights the importance of considering clinical manifestations beyond codified classifications. Suicide risk assessments were inconsistently documented, and preventive measures varied in their implementation, reflecting systemic limitations in the management of mental health within prisons. From a forensic perspective, the comprehensive approach adopted—combining autopsy findings with histological and toxicological analyses—proved essential not only for diagnostic confirmation, but also for excluding alternative hypotheses such as homicide or accidental death. This integrative methodology allowed the reconstruction of complex cases involving multiple self-harm mechanisms and clarified the role of unauthorized drug use within custodial settings. In this way, medico-legal investigations contribute to transparency, judicial reliability, and the safeguarding of human rights, ensuring that deaths in custody are properly classified and contextualized [64,65,66]. The findings of this study reinforce the need for structured suicide prevention strategies that integrate forensic knowledge, psychiatric care, and custodial management. Particular attention should be given to early identification of psychiatric disorders, systematic suicide risk assessments, and the consistent application of protective measures for vulnerable inmates. Investment in these areas is not only a public health and judicial necessity, but also an ethical imperative to protect the dignity and lives of individuals in detention. In light of our findings, we emphasize the urgent need for multidisciplinary and ethically driven approaches to address the ongoing crisis of suicide in custodial settings, ensuring the protection of fundamental human rights and the dignity of incarcerated individuals.