Preventing Suicide and Self-Harm in Jail A Sentinel Events Approach

Sentinel Square


Suicide is the leading cause of death in jails across the country. At a time when the public is paying closer attention to local jails and their primary role in mass incarceration, it is critical to shine light on the problem of jail suicide and the steps jails can take to prevent future deaths. This report is the second from Vera that frames suicide and self-harm in correctional facilities as “sentinel events” that signal a breakdown in underlying systems of care.

Vera’s first report provided practical guidance on how to conduct a sentinel event review—an all-stakeholder, nonblaming, and forward-looking examination of the error—in the aftermath of a suicide in custody. In this report, Vera shares lessons learned from an in-depth study of how four county jail systems review and respond to incidents of suicide and self-harm and the feasibility of integrating sentinel event reviews into those jails’ regular practices.

Key Takeaway

Jails that adopt sentinel event reviews will not only demonstrate leadership and commitment to advancing the field of suicide and self-harm prevention, but will also help instill a new culture in their facilities—one that promotes the safety and well-being of the people in their custody and those who work there.

Publication Highlights

  • At their core, sentinel event reviews require a culture that is committed to addressing system weaknesses in order to prevent future adverse outcomes, instead of a culture of blame that is fixated on identifying bad apples

  • Strong collaboration and effective communication are vital to create the conditions that prevent incidents of suicide and self-harm and can also foster space for sentinel event reviews and corrective action when an event occurs.

  • Vera’s key recommendations are for these jurisdictions to develop suicide prevention plans that are consistent with national standards, seek out guidance on conducting robust reviews, and consistently review incidents of nonlethal self-harm.

Key Facts


Creating a Culture of Safety

Sentinel Event Reviews for Suicide and Self-Harm in Correctional Facilities

Since 2011, the National Institute of Justice (NIJ), through its Sentinel Events Initiative, has been investigating the feasibility of using a sentinel events approach to review and learn from errors in the criminal justice system such as wrongful convictions, eyewitness misidentifications, or incidents of suicide and self-harm in custody. Recogniz ...

  • Leah Pope, Ayesha Delany-Brumsey
December 16, 2016

First-Episode Incarceration

Creating a Recovery-Informed Framework for Integrated Mental Health and Criminal Justice Responses

The number of people diagnosed with serious mental illness in the U.S. criminal justice system has reached unprecedented levels. Increasingly, people recognize that the justice system is no substitute for a well-functioning community mental health system. Although a range of targeted interventions have emerged over the past two decades, existing ap ...

  • Leah Pope, Kim Hopper, Chelsea Davis, David Cloud
January 29, 2016