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A Sentinel Events Approach to Addressing Suicide and Self-Harm in Jail (2019)

Suicides and self-harm are endemic to our nation’s jails, with suicide the leading cause of mortality for jail inmates. Given the high incidence of suicide and serious self-harm in corrections facilities, it is important for corrections agencies, including staff, to understand the causes of these incidents and improve policies and practices to minimize their occurrence.

This study aims to deepen understanding of the current practices jails use in reviewing and responding to incidents of suicide and self-harm and to explore the feasibility of integrating sentinel event reviews into four county jail systems. A sentinel event review approach, adapted from similar processes conducted in fields such as aviation and medicine, is intended to bring together health and correctional staff to examine and then respond to underlying systemic problems that contribute to self-harm in jails. The process is non-blaming and forward-looking, with representatives from all aspects of the system participating along the way. Ultimately, reviews of this kind are intended to prevent future errors from occurring by instilling an ethic of shared responsibility and a culture of safety.

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