Projects: A Sentinel Events Approach to Addressing Suicide and Self-Harm in Jail

Preventing suicide and other forms of serious self-harm is a major challenge facing correctional systems across the country. Suicides account for about one-third of all deaths occurring in U.S. jails each year—more than any other cause. Correctional systems often respond to suicidal behaviors with reactive measures that may address individual behavior but fail to consider the full range of systemic factors at play. However, instances of suicide and self-harm in jails are “sentinel events”, indicating a breakdown in the systems responsible for ensuring inmates’ safety. 

Vera is undertaking the first applied-research project to apply a sentinel events approach, developed in fields such as aviation and medicine, to address systemic problems that contribute to self-harm in correctional settings. The project will improve collaboration between health and justice authorities responsible for reviewing acts of serious self-harm and reduce the incidence of these events in correctional facilities.

This study will:

  • Test and adapt the sentinel events approach to address jail suicide and serious self-harm;
  • Document systemic factors that lead to jail suicide or serious self-harm and develop remedial actions;
  • Develop guidance on how New York City agencies can use the sentinel events approach to minimize rates of suicide and serious self-harm in jail; and
  • Develop the sentinel events methodology as a national standard practice response to jail suicides and serious self-harm. 

Why This Work Matters

Given the high incidence of suicide and serious self-harm in correctional settings, it is important for correctional agencies, including corrections staff, to understand the causes of these incidents and to improve policies and practices to minimize their occurrence. This study will make an important contribution to an emerging body of scholarship that aims to apply theory, methodology, and tools used in medicine and public health to improve behavioral health outcomes for people involved in the criminal justice system.



This project was supported by Award No. 2014-IJ-CX-0030 awarded by the National Institute of Justice, Office of Justice Programs, U.S. Department of Justice. The opinions, findings, and conclusions or recommendations expressed in this web page are those of the author(s) and do not necessarily reflect those of the Department of Justice.


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Director, Substance Use and Mental Health Program