The idea of an all-stakeholder, non-blaming, forward-looking error review process has significant promise for addressing the problems of suicide and self-harm in correctional facilities. Rather than pointing to individual error as the cause of these incidents or painting them as isolated cases, a sentinel events approach encourages an ethic of shared responsibility where all parties work together to understand what happened when someone dies from suicide or is injured by self-harm and to prevent similar events from happening in the future. The goal is to create a “culture of safety” that is characterized by an atmosphere of trust, flexibility, and a willingness to learn about and adjust systems.65 Correctional facilities that adopt sentinel event reviews will not only demonstrate leadership in the field and contribute to the development of a new approach, but will also help to instill a new culture within their facilities that better ensures the safety and well-being of those under their custody.

            Although correctional facilities may have to adapt the sentinel event review process described here to account for jurisdiction-specific issues, these materials identify a way forward for systems looking to implement a more routine and transparent response to suicide and self-harm. Instilling an ethic of transparency and accountability in correctional settings is challenging within a system that is historically adversarial. With leadership and commitment, however, a sentinel events approach can help correctional systems find partners and solutions, rather than critics and blame.