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Sentinel Events Approach to Jail Suicide and Self-Harm

NCJ Number
Date Published
June 2019
19 pages
This is the Final Summary Overview of the findings and methodology of a study that builds an evidence base for the feasibility of "sentinel event reviews" in the criminal justice system, with a focus on preventing suicides by jail inmates.
A "sentinel event" is defined as "a significant negative outcome that signals underlying system weaknesses, is likely the result of compound errors, and may provide, if properly analyzed and addressed, important keys to strengthening the system and preventing future adverse outcomes." The "sentinel event review" is characterized by an all-stakeholder, non-blaming, and forward-looking examination of the error. It is an institutionalized approach that identifies root causes of a sentinel event and underlying systems failures. The current study drew on research in four county jail systems in answering three research questions: 1) How do the selected jail systems currently review inmate suicides and self-harm? 2) What challenges and successes have they experienced in developing multi-stakeholder reviews and corrective action plans in response to inmate suicides and self-harm? 3) How does the legal and policy landscape in each jurisdiction impact the feasibility of conducting sentinel event reviews in responding to inmate suicides and self-harm? Study results suggest that the design and implementation of any sentinel event review will involve multiple factors that range from how healthcare is delivered to inmates, communication processes in place, the organizational culture of the jail, and the legal system of the state where the jail is located. A forthcoming report from the researchers will provide recommendations for jail-based sentinel event reviews of inmate suicide based on the results of this study. 1 table and a listing of this study's reports and upcoming scholarly products

Date Published: June 1, 2019