Creating a Culture of Safety Sentinel Event Reviews for Suicide and Self-Harm in Correctional Facilities

Culture Of Safety Rectangle


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. Recognizing that adverse situations are rarely caused by a single event or the actions of an individual person, NIJ defines a sentinel event as a significant negative outcome that: 1) signals underlying weaknesses in a system or process; 2) is likely the result of compound errors; and 3) may provide, if properly analyzed and addressed, important keys to strengthening the system and preventing future adverse events or outcomes.

With funding from NIJ, the Vera Institute of Justice (Vera) has been examining the applicability and appropriateness of using sentinel event reviews for incidents of suicide and serious self-harm in detention. This report focuses on these incidents as prime opportunities to implement sentinel event reviews in the criminal justice context.