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

From the Director

People enter prison and jail at a low point in their lives and are particularly vulnerable to violence of all kinds—including self-harm and suicide. Although the rate of suicide in jails has decreased by 50 percent since the 1980s, it continues to be the leading cause of death, far outpacing rates seen in the community. While it is important to acknowledge the progress that has been made in addressing suicides in custody, there is still much room for improvement. With recent years having seen increases in the rate of suicides (since the lowest point in 2008), there is an urgent need for action. 

The corrections community has much to learn from medicine. When a death or other serious negative outcome occurs in a hospital or other community health setting, it is seen as a “sentinel event,” signaling a breakdown in systems of care. The sentinel event framework acknowledges that, to prevent similar incidents in the future, it is insufficient to assign blame to a person or people. Rather, it is necessary to collaboratively develop and implement systems-level solutions to prevent similar tragedies from happening in the future. 

Framing suicide and self-harm in correctional facilities as sentinel events and targeting them for collaborative, forward-thinking reviews is an important step towards ensuring the safety of people held in corrections. This report is designed to provide practical guidance on how correctional agencies can learn from other fields to better protect the people entrusted to their care.

President's Signature

Jim Parsons

Vice President, Research, Monitoring, Evaluation & Learning