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

Suicide is the leading cause of death for people incarcerated in jail in the United States, accounting for more than 30 percent of deaths. In 2014, the rate of suicide in local jails (50 per 100,000) was the highest observed since 2000 and remained more than three times higher than rates of suicide in either prison (16 per 100,000) or in the community (13 per 100,000). Despite the fact that jail suicide is increasingly recognized as a serious public health problem, the relatively stable rate of jail deaths by suicide across the last 20 years suggests that progress in jail suicide prevention has stalled. The majority of jails in the United States (63 percent) do not conduct mortality reviews following a jail suicide. Further, review processes in the criminal justice system traditionally have been adversarial, driven by an approach that assumes a “bad apple” operator is responsible for error and responds by ascribing blame rather than seeking out the underlying system weaknesses that may more accurately be responsible for the bad outcome. The lack of a system-wide approach inhibits an honest assessment of what happened in these cases and, in turn forecloses opportunities for staff and corrections leaders to learn from mistakes and prevent future incidents of suicide and self-harm.