The county's program uses a protocol called QPR, which stands for Question, Persuade and Refer, to recognize signs of emotional distress and suicidal behavior in inmates and effective ways to respond.

At Montgomery County Correctional Center, it is not unusual for more than half the 65 infirmary beds to be occupied by inmates on suicidal precautions, according to officials.

Reports of attempted suicide at the jail more than tripled — from eight to 45 — between 2012 and 2017, according to state corrections data.

Jail officials attribute the dramatic increase to a policy that categorizes any suicide risk referral as a suicide attempt, as well as efforts to increase staff vigilance to better identify inmates experiencing distress.

In September, two dozen newly hired Montgomery County corrections officers spent the day learning what to do if an inmate threatens suicide — as well as what they should never do.

“Don’t brush it off,” Warden Julio Algarin told the officers.

The warning was repeated often during a training devoted exclusively to suicide awareness and prevention.

While suicide risk is among the topics the prison’s 65 corrections officers routinely cover in annual training sessions, the September session was the first one to address the issue in depth, Algarin said.

The Eagleville correctional center implemented the training in April, not long after the prison experienced what coroner data shows was its third inmate suicide in less than six months.

The program uses a protocol called QPR, which stands for Question, Persuade and Refer, explained Anna Trout, a community mental health program specialist who led the training. The focus is on educating corrections staff to recognize signs of emotional distress and suicidal behavior in inmates and effective ways to respond.

“Hope is not lost until that person is gone,” Trout explained at the September training. “So as much as we can intervene, that is what we want to do.”

The Bucks County prison started training new hires in QPR techniques two years ago, said Donna Duffy-Bell, who heads the county’s department of mental health/development programs, who handles the training. PrimeCare Medical oversees the annual re-training for existing staff, Duffy-Bell added.

Over the last decade, many U.S. jails have implemented suicide prevention procedures and trained staff to recognize common risk factors, efforts generally driven by wrongful death lawsuits, said forensic psychologist Michele Galietta, a professor at John Jay College of Criminal Justice in New York City.

But the effectiveness and thoroughness of those programs depends on how seriously the top administrators take suicide prevention, she added.

“It’s not about how many people you have, it’s do you care. Are they just filling out a form or do they understand the purpose of the assessment and feel an obligation to care for these people,” Galietta said. “Are you just trying to meet the minimum standards or are you trying to make a change?”

Available national statistics show roughly one quarter of jail suicides happen within the first 24 hours of incarceration, but nearly as many occur weeks later. For that reason, corrections staff need to be trained to watch for inmate behavior changes, especially around significant events like court dates, cell block transfers or after visits and phone calls, mental health experts point out.

“The officers need to know mental health because they are the ones who spend the most time with inmates,” said Galietta, a recognized expert in suicide risk assessment and prevention in correctional settings.

The most effective corrections suicide prevention programs include ongoing training for all prison staff, added Christine Tartaro, a professor of criminal justice at Stockton University in southern New Jersey and an expert in suicide in correctional settings. She pointed out that frequently after an inmate suicide happens, prison officials learn that corrections officers noticed suspicious behavior, but didn’t know where to report it.

“Everyone in the jail needs to be involved,” Tartaro added. “You never know who is going to hear something or see something and that information has to be taken, communicated, to the correct authorities.”

Galietta has trained correction officers on the best ways to interact with inmates to determine their mental status, as well as how they can help inmates develop coping and problem-solving skills that reduce suicidal thoughts.

What death investigations frequently turn up is multiple breakdowns occurred in the inmate risk-assessment process, said Galietta, who has participated in such reviews. Either an inmate did not speak to a medical professional, no one asked about prior suicide attempts or the jail had information but nothing was done with it, she said.

Another common mistake is assuming if an inmate hasn’t attempted self-harm the danger has passed, she added.

During the Montgomery County training, corrections officers were told if they learn an inmate has experienced a recent personal loss or setback, a report should immediately be filed with prison medical staff and a suicide risk assessment recommended, said Cpl. Kevin Patton, a Montgomery County corrections officer who assisted in the training. Only medical staff can initiate, modify or discontinue a suicide watch.

Patton also emphasized the importance of officers informing staff on the next shift about inmates displaying suspicious behavior.

One of the biggest challenges with suicide prevention in correctional centers is getting staff to take suicide threats seriously, Tartaro said.

“The staff members don’t want to get played. They don’t want to fall for someone who is faking it. So there is a temptation to weed out who is mad versus bad,” she said. “If you are not a qualified mental health professional, you shouldn’t be trying to make that decision.”