Suicides of inmates incarcerated in CSC penitentiaries are thoroughly investigated by a board consisting of at least three individuals, including a psychologist. This board interviews staff, inmates, and others who were associated with the inmate and the events surrounding the suicide. Board members visit the specific location of the suicide and examine such issues as suspected motivations, the emergency response, and assistance to staff and inmates in dealing with the aftermath of the suicide. The board completes a comprehensive report that includes recommendations to prevent future similar occurrences. In particular, the psychologist profiles the inmate in terms of his or her criminal background, social and psychological history, and emotional state immediately prior to the suicide. Of 66 inmates who committed suicide between April 1992 and March 1996, 98 percent were male, 65 percent were single, 45 percent were between 30 and 39 years of age, 44 percent suffered from antisocial personality disorder or other personality problems, and 27 percent were seeing a psychiatrist or a psychologist for counseling at the time of the suicide. Data also showed 97 percent of inmates came from a dysfunctional family background and 59 percent had a history of alcohol or drug abuse. Most suicides (83 percent) were accomplished by hanging, and 70 percent occurred at night. Suspected motivating factors were family problems (29 percent), denial of a request (26 percent), fear of or problems with other inmates (24 percent), substance abuse (21 percent), sentence length (18 percent), drug debts (17 percent), and mental health problems (17 percent). Although the institutional response to suicide was considered quick, responsible, and professional in 65 percent of the cases, problems were associated with the remaining cases. These problems most often concerned lack of available emergency equipment and staff training deficiencies in how to respond to emergencies. Recommendations on how to prevent inmate suicides are offered that focus on communication, the quality and frequency of rounds, access to emergency equipment, and staff training in emergency procedures. 6 tables