By Rachel Crumpler

When the calls from prison suddenly stopped in February 2024, Erik Ramsey’s family started worrying. Frequent communication was their way of trying to help Ramsey, 29, who’d been diagnosed with schizophrenia and bipolar disorder, get through the time until his scheduled release in February 2026.

In isolation, Ramsey couldn’t make or receive calls. He did send a few letters full of manic ramblings that raised concerns among his loved ones. 

Then came May 5, when a call just after midnight from the warden at Harnett Correctional Institution blindsided Ramsey’s family. 

“Erik took his life,” Ramsey’s older brother Edward recalled the warden telling him.

“It was just a shock,” said Edward Ramsey, whose brother had been in prison for less than four months. “I hadn’t been able to talk to my brother for months … I thought I was in a dream … To this day, it’s still difficult to understand and to process that it happened.”

A correctional officer found Ramsey dead in his restrictive housing cell — a sheet tied around his neck hanging from the bars of his cell door — while making rounds around 11 p.m. on May 4, according to a state medical examiner’s report obtained by NC Health News.

About an hour prior, Ramsey had told a correctional officer that he “needed to talk to someone,” the report states, but the officer said he was busy making rounds and said they would talk later. Ramsey had also refused to take his mental health medication earlier in the day, according to the report.

“There was no reason for prison to be a death sentence,” Austin Holland, Ramsey’s stepbrother, said. “Erik was the baby of the family. He was the joy.”

Ramsey’s is just one story, but it connects to larger trends among people serving time in North Carolina prisons: an uptick in suicides in 2024, rising numbers of people with mental health diagnoses and the ongoing use of solitary confinement, which the prison system refers to as restrictive housing.

Last year, 13 people died by suicide — tying the record for most suicides in a year. Eight of the deaths occurred in restrictive housing, where offenders are confined alone in a cell about the size of a parking space for 22 hours or more per day. 

To start 2025, three people died by suicide over four days in January — two in restrictive housing. 

No more suicides have been reported since the Jan. 19 death of 25-year-old David Whittington, who had been in prison since July 2024 for assault on a law officer and revocation of his post-release supervision; he was projected to be released in September. The medical examiner’s report notes that Whittington had many mental health diagnoses and a history of suicidal ideation, along with a prior suicide attempt, and that he had been on suicide precautions at the prison about one week before his death.

Lewis Peiper, director of behavioral health at the Department of Adult Correction, told NC Health News that his department has put a number of new programs in place to address mental health issues but that it’s hard to pinpoint any one factor driving increases in deaths by suicide.

“We find that over time, pinning [suicide] down to just one thing seems to be kind of a moving target of sorts,” Peiper said. 

Peiper said the corrections department is focused on bolstering training, especially for prison behavioral health staff and correctional officers who have the most contact with incarcerated people. However, one of the prison system’s biggest projects developing a new suicide prevention training program in partnership with UNC Charlotte researchers was just put on hold; the Trump administration cut off the federal grant that funds the work.

Records show that Ramsey landed in isolation in early March because he received infractions for assaulting a staff member and subsequently for trying to escape — behavior his family believes was a manifestation of his mental illness.

More than eight months after his death, when his autopsy report was released in mid-January, Ramsey’s family learned about the gravity of Ramsey’s mental distress. According to notes in the medical examiner’s report, Ramsey made multiple suicidal statements during his time in prison and even attempted suicide the month before his death by eating batteries and taking pills.

That information came as a body blow to members of the family, Holland said. They were not aware he was in crisis and were outraged that they weren’t given the opportunity to talk to Ramsey to try to get through to him amid his mental health struggles.

“Him not talking to us was the punishment for him being mentally ill and having manic moments,” Holland said. “They took away the thing that could have helped him.” 

Department of Adult Correction Communications Director Keith Acree said the department does not notify family members about suicide attempts — unless the attempt results in hospitalization or a critical medical condition — as that information would be considered protected health information that cannot be disclosed without an individual’s written authorization. He also said that telephone privileges in restrictive housing are “not automatic” and are determined by the prison warden based on control and safety considerations.

Acree said he could not comment on Ramsey’s case, citing department policy.

‘Signal of a failing system’

The Department of Adult Correction announces when a suicide occurs by posting a news release on its website. NC Health News requested the medical examiner’s investigation and autopsy reports for each person who died by suicide going back to 2016. They contain varying degrees of detail. Some provide more insight into contextual circumstances, such as histories of mental illness and substance use, a recent sexual assault or disputes with other incarcerated people. Other reports just have a brief account of the timeline of finding a person dead.

Since 2016, a total of 81 people have died by suicide in North Carolina prisons. Nearly 60 percent have occurred in restrictive housing.

People in prison disproportionately have higher rates of mental illness than the general population, as well as higher rates of self-harm. 

Based on NC Health News’ analysis of the deaths, about three-quarters of suicides are among white men, though less than half of the total prison population is white. Only four have been women. 

Of those who died by suicide, it’s a mix of people who had life sentences or decades left to serve and others nearing their release dates. Fourteen people who took their lives had less than one year left to serve.

For example, 28-year-old Samuel Shore was due to be released from prison in April but instead died by suicide at Greene Correctional Institution in January after serving close to three years for driving while intoxicated. 

“When people are dying inside prisons by suicide, I think that’s a signal of a failing system — a broken correctional system that relies on punishment instead of rehabilitation,” said Craig Waleed, project manager for Unlock the Box, a campaign against solitary confinement at Disability Rights NC. 

Increasing deaths

Suicide numbers appear small stacked up against the nearly 32,000 people in the Department of Adult Correction’s facilities every day. But on average, the rate of suicide in prison is slightly higher than North Carolina’s overall suicide rate. North Carolina’s suicide rate from 2013 to 2022 was 15.5 people per 100,000 on average, while the state prison’s suicide rate was 19.6 per 100,000 on average during the same 10-year timeframe.

Over the past decade, the number of annual suicides in prison has gone up and down, but the jump in 2024 is striking. 

The prison suicide rate in 2024 was equivalent to 40.8 people per 100,000 — likely more than two times the overall state rate, which has held fairly steady over the past decade. North Carolina’s overall suicide state rate in 2022 — the last year of complete data — was 16.5 people per 100,000.

North Carolina isn’t alone in facing an increase in prison suicides. Nationwide, suicide is a leading cause of death in correctional facilities. From 2001 to 2019, the number of suicides increased by 85 percent in state prisons and 61 percent in federal prisons, according to data from the Bureau of Justice Statistics.

Kate LeMasters, a researcher at the University of Colorado Anschutz School of Medicine who has studied suicides in correctional facilities — including in North Carolina prisons — said that these deaths shouldn’t be happening. Prison systems are tasked with maintaining the safety and security of those in their custody, and that includes keeping people alive, she said. 

While advocates and researchers acknowledge that zero suicides may not be possible, they say rising deaths are a sign of trouble.

“Suicides in prison is a public health crisis,” LeMasters said. “These deaths should not be happening. We’ve created, and are increasingly reliant on, a system that’s not set up to handle and improve people’s mental health.

“An increase in suicide is indicative of the bigger mental health crisis happening in these facilities,” she said.

Growing mental health caseload

The increase in suicide deaths comes at a time when an increasing proportion of people in North Carolina prisons have a diagnosed mental illness. Over the past decade, the percentage of the prison population on the mental health caseload has doubled, according to department data. Now, one-quarter of the prison population — about 8,000 people — has a mental health diagnosis requiring treatment, Peiper said.  

The prison system’s mental health caseload has grown by 2,000 people since 2020, and Peiper said it’s a challenge to meet the rising need.

Peiper said he needs more staff to do this work, but he wouldn’t go so far as to say the suicides show a gap in mental health care.

“Because the numbers vary from year to year, I don’t know if that could account for the years that were lower where we still had a lot of people needing mental health treatment and increased staffing needs,” Peiper said.

Peiper also noted that many people who commit suicide are not on the mental health caseload.

“They are overlapping populations, but they’re not the same population,” he explained. 

That’s consistent with the medical examiners’ reports reviewed by NC Health News; only a portion of the cases included medical histories of mental health disorders like depression, bipolar disorder, post-traumatic stress disorder and others. 

The vast majority of suicides in North Carolina prisons have been by hanging — most commonly using a bed sheet — according to NC Health News’ review of the cause of death on autopsy reports. Another eight were from overdoses. The cause of death in 10 suicides remains pending, as medical examiners’ reports haven’t been made public.

In addition to suicide, the Department of Adult Correction encounters a range of other self-injurious behaviors among its population.

In 2024, 2,941 self-harm incidents occurred that required a self-injury risk assessment, according to department data provided to NC Health News. Of those, 32 percent included some type of action, such as cutting or burning oneself with scalding water, while the remaining 68 percent were written or verbal threats. 

Peiper said the prison system’s policy is to place people deemed suicidal under “constant observation” where they are placed in a cell with line-of-sight of the person and given tear-resistant items, such as a safety blanket, safety smock and vinyl-covered mattress. A behavioral health clinician meets with the incarcerated person daily to assess their safety and whether they can return to their regular housing unit, he said. 

After Ramsey’s suicide attempt a month before his death, he was replaced on this suicide behavioral watch for one day, according to his medical examiner’s report.

Mental deterioration

In addition to many people coming to prison with mental illnesses, incarceration itself can also cause mental deterioration and anguish. Research shows higher rates of self-harm among incarcerated populations.

Ramsey fits these trends. He was sent to prison for a string of armed robberies his family said he committed in 2019 amid deteriorating mental health. After his arrest, he was diagnosed with schizophrenia and bipolar disorder. 

His mental health stabilized after he was given psychiatric medication, his family said. And when Ramsey entered prison in January 2024, his family had already made plans for how best they could support him — top among them was staying in frequent communication.

They created a schedule. Ramsey called his stepbrother on Mondays, his brother on Wednesdays and his parents on Fridays. His family members made sure to pick up every call.

“Hearing from us — that was his way of staying grounded,” said Holland. “He knew that for him to stay rooted in reality, he needed to hear from his family.”

Some days when they talked he sounded tired, but Holland said his brother was always looking toward the future — eyeing his 30s as a fresh start.

But then, his family said, the phone communication vanished once Ramsey was placed in restrictive housing in March. That put the family on edge, but a prison staff member told Ramsey’s father in April that he could visit him in a month on May 21, and they set their sights on that.

But the visit never happened. By that time, Ramsey was dead. 

Ramsey’s family is convinced that prison, particularly time in solitary confinement, worsened his mental health symptoms and that he couldn’t get the help that he needed. 

“Erik never attempted suicide while not in prison,” Holland said. “This wasn’t a foregone conclusion. This wasn’t a kid who had been depressed since he was eight and was always going to end this way. That’s not this story.”

Research consistently shows that solitary confinement affects physical and mental health, increasing risks of anxiety, self-harm and suicide. 

Waleed from Disability Rights NC knows firsthand the toll of solitary confinement. He spent two 30-day stints locked in a restrictive housing cell alone for all but one or two hours a day while incarcerated in New York. He said it only took a few days before he felt himself start to unravel and he began hallucinating.

“If someone is in a situation like that, long enough, they begin to doubt everything about what is real and what isn’t — even their own reality or their own existence,” Waleed said.

Records show that Ramsey was in restrictive housing for nearly two months before he died by suicide. NC Health News analyzed a database compiled by Disability Rights NC that contains the housing status of people in the state prison system based on weekly data posted by the Department of Adult Correction. The database revealed that others who died by suicide in restrictive housing spent as little as one week there before their death, including two of the three suicides this year. The third person who died by suicide in 2025 spent about a year in restrictive housing before his death for various infractions from flooding his cell, disobeying orders and assaulting staff.

Increased risk of suicide in solitary

Christine Tartaro, a researcher at Stockton University in New Jersey who has studied correctional suicide for over 25 years, said time spent in solitary puts people at higher risk for suicide. 

“When people are alone, not only is there possible motivation to take one’s life, but the opportunity grows exponentially,” Tartaro said. “People are only looking in on you every once in a while, and suicide by hanging only takes a couple of minutes.”

Despite the known harms of solitary confinement, about 6 percent of North Carolina’s nearly 32,000 incarcerated people are held in restrictive housing.

Tartaro, who has studied state and federal suicide prevention plans across the nation, said one of the ways states have sought to prevent suicide deaths is by reducing restrictive housing. That’s because corrections departments across the nation — including in North Carolina — have consistently found more suicides occur there.

For years, advocates have been pushing for the Department of Adult Correction to reduce — and even eliminate — the use of solitary confinement. They have called on the prison system to adopt the Nelson Mandela Rules — a set of standards on the treatment of incarcerated people worldwide that prohibits prolonged solitary confinement of more than 22 hours a day for more than 15 consecutive days. 

Former Gov. Roy Cooper’s Task Force for Racial Equity in Criminal Justice recommended implementing this standard in 2020, but then-Secretary Todd Ishee said he didn’t think complying was feasible and was slow to make changes.

But the Department of Adult Correction’s new secretary, Leslie Cooley Dismukes, who assumed the role in January, told NC Health News that the department is working toward following the Nelson Mandela Rules. 

Changes are being made in three phases, she said. First, the department revised its disciplinary policies in December to reduce lengths of stay in restrictive housing for certain infractions and is working to streamline the disciplinary investigation process. This summer, the department also plans to enhance step-down and diversion housing to facilitate more alternative options to restrictive housing or smooth the transition back to the general population.

Advocates are hopeful these reforms to restrictive housing can make a difference.

“I think that it’s important to stop putting so many people in solitary confinement because what we find is that many times people are in solitary confinement not because they’re the worst of the worst, but because they’re feared of being violent, or they’ve had some other type of infraction, or the manifestation of some type of psychosis,” Waleed said. 

When placing someone in restrictive housing, Peiper said, additional behavioral health screenings are required to assess one’s mental health as well as extra monitoring by correctional officers. That’s in recognition that it’s often a more vulnerable setting.

“There’s a ramp up of eyes on, increase of screening, increase in contacts that are occurring,” Peiper said.

However, he said that the Department of Adult Correction tries to place people with mental illness in alternative settings from restrictive housing, such as inpatient psychiatric treatment units at Central Prison or the North Carolina Correctional Institution for Women. Therapeutic diversion units — treatment-oriented prison housing units for people with a mental illness staffed by behavioral and nursing professionals in addition to correctional officers — with 68 total beds across three prisons and behavioral health outpatient treatment units with 300 beds across another four prisons are also an option, he said. 

In 2024, 67 people went to the therapeutic diversion units, according to department data shared with NC Health News. These units, first implemented in 2016, have been studied and shown to reduce disciplinary infractions and self-harm while an incarcerated person is placed there, but a further study revealed that rates of self-harm increased once a person returned to regular population housing.

While the studies demonstrated that the treatment units have positive impacts, Peiper said expanding these treatment slots would require a significant increase in funding, staffing and space. 

Those are resources the Department of Adult Correction doesn’t currently have, particularly as the system has struggled with chronic staffing shortages since the pandemic. Overall, the Department of Adult Correction — an agency with more than 18,000 full-time employees — has a vacancy rate of 24 percent, according to a March 4 presentation to state lawmakers. Health care positions have an even higher vacancy rate of 28 percent. 

As a result of resource constraints, Peiper said the Department of Adult Correction’s behavioral health team developed a model for a new housing unit to serve people with mental health issues that required less staff: outpatient treatment units. Offenders housed in these units receive routine group and individual therapy sessions and additional monitoring and support.

The first behavioral health outpatient treatment unit launched at Maury Correctional Institution in November 2021, and since fall 2024, three more prisons have opened these units. According to department data, by the end of 2024, these units had 1,059 admissions.

While these options exist, they only serve a fraction of the 8,000 people on the Department of Adult Correction’s mental health caseload. As a result, NC Health News still found examples, such as Ramsey’s, where people with diagnosed mental health issues landed in restrictive housing anyway. A department spokesperson said they could not comment on whether alternatives to restrictive housing were considered for Ramsey.

Forty-year-old Henry Bost, diagnosed with depression and on the prison system’s mental health caseload, spent about four months in restrictive housing before he died by suicide on May 4, 2022 — less than a year before his projected release. Before that, he had been in and out of isolation for weeks at a time throughout 2021 for various infractions. Since that January, he had been seen once per month by mental health staff but refused his scheduled appointment on April 26, saying he was “having a bad day” but denied suicidal ideation, according to the medical examiner’s investigation note.

‘An opportunity to come home’

After each suicide, Peiper said an interdisciplinary team of prison staff discusses and reviews the incident to identify any places for reform.

Peiper said the Department of Adult Correction watches for trends, but it’s often hard to spot patterns for them to intervene in.

This isn’t the first time there’s been a notable increase in prison suicides. 

After an uptick in suicides in 2018 — when 11 deaths occurred — the prison system assembled a Suicide Prevention and Self-Directed Violence Workgroup led by Peiper that met in 2019 to look more closely at suicide prevention. Several recommendations were made in the workgroup’s April 2020 final report, such as improving screening and staff training.

Over the past five years, prison officials have continued to implement and expand initiatives that stemmed from that group, Peiper said. 

One example is a peer observer program, which trains and deploys incarcerated people to observe and engage with fellow incarcerated people in mental distress on suicide watch. The program was first piloted at Mountain View Correctional Institution in 2019 and has since expanded to include 67 peer observers at five prisons across the state. Corrections leaders also established a review committee that meets monthly to discuss system-level plans for some of the most challenging people who have frequent occurrences of self-harm.

But some of the change has come slowly. The first changes to staff training came in 2022 when revisions were made to the annual self-injury and suicide prevention training for all staff. Implementation of some of the group’s other recommendations is still pending. 

Peiper said action has been taken on all of them and the movement forward continues, but there have been challenges. The pandemic diverted energy that would have gone toward implementation of the changes. The Department of Adult Correction became a separate cabinet agency in 2023, and Peiper said the changeover brought new logistical issues. Staffing shortages and funding challenges have also stymied implementation. 

One of the prison system’s largest projects in response to the 2019 workgroup to develop a new suicide prevention training program for behavioral health staff in partnership with UNC Charlotte researchers — one that has already been the subject of academic papers — was expected to be completed in September and rolled out to staff. However, UNC Charlotte received a stop-work order on the project on March 27; the federal government terminated the grant money that had connections to COVID-era funding.

The Department of Adult Correction is also partnering with the American Foundation for Suicide Prevention and the National Institute of Corrections to implement other training efforts.

Peiper said while behavioral health staff have a large role to play in suicide prevention, he’s also focused on getting correctional officers and incarcerated people themselves the knowledge and tools to be aware of warning signs and changes in behavior that could signal suicide risk and how to respond.

Peiper said he hopes the changes they have planned will decrease prison suicides, but he also said suicides are often unpredictable.

For Waleed, who spent eight years incarcerated in New York, the prevalence of suicide in prison is a reflection of what he said is the unhealthy and traumatic environment that takes a toll on those imprisoned, particularly in solitary confinement. Elevated suicide rates among formerly incarcerated North Carolinians point to how the trauma lingers.

About 95 percent of incarcerated people have a release date, and Waleed said they deserve an opportunity to come home. 

Ramsey’s family had already started planning for that day — counting down to February 2026. His father had just retired and was eager to spend his time with Ramsey. Now, they’re unexpectedly adjusting to life without him.

“He should have been safe in prison — enough so that he could have a life,” Holland said. “We really thought that at 30 he was going to get to start over again, and we were excited for it.”

Clarification: The story was updated to clarify that UNC Charlotte received the stop-work order on the suicide prevention training program project, not the Department of Adult Correction.

This story was produced with support from the Investigative Editing Corps through a partnership with Report for America and NC Health News. Melanie Sill was the story editor.

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