Four inmate suicides in quick succession led the agency to ask Lindsay Hayes, Assistant Director of the National Center on Institutions and Alternatives, to help develop a program to improve staff training and facilities to reduce inmate suicides. Hayes suggested an interdisciplinary study of each incident and a mortality review of every completed suicide and serious attempts requiring hospitalization. Other recommendations focused on electronic surveillance; targeting training on correctional officers, because most suicides occur in evenings and on weekends when mental health and medical staff are often not readily available; staggered observation periods; and specific intervention steps when a suicide attempt is discovered. Actions planned or taken to implement the recommendations included the replacement of selected cell doors to expand the observation windows, a plan for immediate transfers to larger institutions of inmates requiring mental health observations, replacement of ventilator mesh in cells intended for inmates who were high suicide risks, and development of a training curriculum based on the five-step program used by the Federal prisons. Hawaii also plans to build an additional prison to stop the current overcrowding problems. Photographs