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July 2019

Preventing Suicide and
Self-Harm in Jail:
A Sentinel Events Approach
Jason Tan de Bibiana, Therese Todd, and Leah Pope

From the Director
Suicide is the leading cause of death in jails across
the country. Each year, more than 300 people take
their lives while incarcerated in America’s jails,
accounting for roughly one-third of all deaths in
custody. Approximately one-quarter of these deaths
occur within 24 hours of confinement and half occur
within the first two weeks. This data paints a bleak
portrait of the acute health risks of incarceration,
demonstrating that even short stays in jail can have
deadly consequences. At a time when the public is
paying closer attention to local jails and their primary
role in mass incarceration, it is critical to shine light on
the persistent problem of jail suicide and the actionable
steps jails can take to prevent future deaths.
This report is the second from Vera that frames
suicide and self-harm in correctional facilities as
“sentinel events” that signal a breakdown in underlying
systems of care. Sentinel event reviews have been
used successfully in the field of medicine for decades

and have much to offer the corrections community.
Based on principles of transparency, inclusiveness,
and systemwide accountability, sentinel event reviews
acknowledge that bad outcomes are rarely the result
of an individual mistake and embrace a forwardlooking approach to safety. Put into practice in jails,
they are one important step toward implementing a
comprehensive suicide prevention plan.
Vera’s first report provided practical guidance on how
to conduct a sentinel event review in the aftermath of
a suicide in custody. Here, we share lessons learned
from an in-depth study of four jails across the country
that are trying to innovate in their responses to
suicide and self-harm. By sharing the practical barriers
and facilitators to implementing comprehensive,
nonblaming review processes, jurisdictions can
learn important lessons about how to improve their
responses to jail suicide and self-harm and, in turn,
better protect the people in their care.

Jim Parsons
Vice President and Research Director
Vera Institute of Justice

This study was supported by Award Number 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 publication are those of the authors
and do not necessarily reflect those of the U.S. Department of Justice.
Additional support was provided in part by a grant from the Clifford
Chance Foundation, Inc.

Contents
1	Introduction
4	Methodology
	

4	 Study sites

	

4	 Study activities

6	

Jails’ current responses to suicide and self-harm

9	

Creating the conditions for sentinel event reviews

	

9	 Health care delivery model	

	

12	 Collaboration and communication

	

15	 Organizational culture

	

21	 Legal landscape

27	Conclusion
29	Appendix
32	Endnotes

Introduction

S

uicide is the leading cause of death for people incarcerated in jail in the
United States, accounting for more than 30 percent of deaths in custody.1
In 2014, the rate of suicide in local jails (50 per 100,000 people) 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).2 Although the rate of jail suicide dropped dramatically between
1986 and its low point in 2008 (from 107 to 29 per 100,000 people), the rate
has since fluctuated between 40 per 100,000 and 50 per 100,000.3 Mortality
rates in jail are highest for men and white people, and this is even more
pronounced for jail suicide: men incarcerated in jail are 57 percent more likely
to die by suicide than women, and white people who are incarcerated are 5.25
and 3.5 times more likely to die by suicide than black or Latino people.4 These
deaths do not account for the incidence of nonsuicidal self-harm in jails, a
phenomenon that is less well researched but also a significant health concern
and an ongoing challenge in correctional facilities. Although there is little data
on self-harm in jails, there is good reason to believe it is common. A national
survey of U.S. prisons found that 2 percent of people who are incarcerated
engaged in self-injurious behavior each year and that 85 percent of prisons
reported that it happened at least weekly.5
There are multiple reasons for elevated rates of suicide and self-harm
in jails. People incarcerated in jail may face facility-level risk factors such
as overcrowding; situational risk factors such as the stress and isolation of
incarceration; and individual risk factors such as mental illness, substance
use, a history of trauma, or a history of engaging in self-harm or suicide
attempts. Although suicide is not in itself a mental illness, it may be the
result of undiagnosed or untreated mental health disorders, and decades
of research show that correctional systems in the United States are illequipped to meet the underlying needs of people with mental illnesses.6
A 2017 survey from the Bureau of Justice Statistics found that 26 percent
of people incarcerated in jail met the threshold for serious psychological
distress in the past 30 days (compared to 5 percent in the general
population), yet only one-third (35 percent) of them had received mental
health treatment since admission to jail.7

Preventing Suicide and Self-Harm in Jail: A Sentinel Events Approach

1

This complex interplay of risk factors makes suicide prevention in jails
exceedingly challenging. Despite progress since the 1980s, the relatively
stable rate of jail suicide across the last 20 years suggests that progress in
prevention has stalled.8 Experts note that the approach to suicide prevention
adopted by most jails includes a narrow focus on managing people when
they are on suicide precautions and that suicide rates will only be reduced
when facilities adopt a comprehensive suicide prevention program.9 It is
thus critical that jails receive guidance in developing and implementing such
a prevention program and that criminal justice stakeholders continue to
innovate in their responses to suicide and self-harm.
In 2016, the Vera Institute of Justice (Vera) reported on the potential
for addressing the problem of jail suicide and self-harm through “sentinel
event reviews.”10 Recognizing that failures to prevent jail suicide or
self-harm are rarely the result of a single event or the actions of an
individual staff member, Vera explored the potential of understanding
jail suicide as a sentinel event: 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 harm.11 Many high-risk
fields like aviation and medicine have long responded to known errors
by implementing review processes characterized by an all-stakeholder,
nonblaming, and forward-looking examination of the error.12 These sentinel
event reviews move away from a view of error as solely the product of
individual negligence and instead encourage an institutionalized approach
that identifies root causes and underlying system failures.13
Vera is part of an expanding group of researchers and practitioners
supported by the National Institute of Justice that seeks to understand the
feasibility, impact, and sustainability of adopting sentinel event reviews in
the criminal justice system. In an earlier report, Vera provided justification
for why the problem of jail suicide and self-harm is well-suited to a
sentinel events approach and offered a step-by-step guide for conducting
such a review and moving jails beyond their all-too-common adversarial
approach to reviewing suicide deaths in custody.14 (See “Conducting a
sentinel event review” at page 2.) Since the publication of that report, Vera’s
researchers have studied how four county jail systems review and respond
to incidents of suicide and self-harm and have explored the feasibility
of integrating sentinel event reviews into those jails’ regular practices.
Although best practices for suicide prevention and response exist, the
majority of jails in the United States (63 percent) do not conduct mortality
reviews following a jail suicide and few institutionalized responses exist

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to respond to instances of self-harm.15 Research such as this is therefore
critical. Not only does this study build the evidence base for the feasibility
of sentinel event reviews in the justice system, but it also provides rich
data on why the problem of jail suicide remains such an intractable
systems issue in the United States and how some jurisdictions are trying to
innovate their responses.
Conducting a sentinel event review
For expert guidance on how to conduct a sentinel event
review, see Vera’s report Creating a Culture of Safety:
Sentinel Event Reviews for Suicide and Self-Harm in
Correctional Facilities and guidance from the Sentinel Events
Initiative at the National Institute of Justice.a Sentinel event
reviews take a “root-cause analysis” approach, guiding
practitioners through the following eight steps:

3.	 describe the event/create a timeline;
4.	 identify contributing factors;
5.	 identify the root cause(s);
6.	 develop an action plan;
7.	 share lessons learned; and

1.	 identify the sentinel event;

8.	 measure the success of corrective actions.

2.	 gather a multidisciplinary team;

Leah Pope and Ayesha Delany-Brumsey, Creating a Culture of Safety: Sentinel Event Reviews for Suicide and Self-Harm in Correctional Facilities (New York: Vera

a

Institute of Justice, 2016), https://perma.cc/FF7Q-VT43; and National Institute of Justice (NIJ), “NIJ’s Sentinel Events Initiative,” https://perma.cc/UM2W-WZSG.

This report presents the findings from Vera’s recent study. Vera
collaborated with leadership and staff in four geographically diverse jail
systems over 18 months: the Middlesex Office of Adult Corrections and
Youth Services (MCDOC) in Middlesex County, New Jersey; the Middlesex
Sheriff’s Office (MSO) in Middlesex County, Massachusetts; the Pinellas
County Sheriff’s Office (PCSO) in Pinellas County, Florida; and Spokane
County Detention Services (SCDS) in Spokane County, Washington. This
report first presents data on the jails’ current responses to suicide and
self-harm and then describes the barriers and facilitators to implementing
sentinel event reviews. Recommendations are provided throughout for
jurisdictions looking to improve their responses to jail suicide and selfharm through the incorporation of sentinel event reviews.

Preventing Suicide and Self-Harm in Jail: A Sentinel Events Approach

3

Methodology

V

era’s study included four jail systems. For each system, Vera
researchers undertook an administrative document and policy
review and then conducted site visits and interviews with jail and
health leadership and staff. In addition, Vera worked with the law firm
Clifford Chance to analyze the legal landscape of liability, discovery, and
public record requests in each jurisdiction and to understand the potential
implications for jails and sentinel event reviews.

Study sites
Vera selected four jail systems after outreach to 16 sites about the study and
conversations with six sites. The four systems were selected due to their
diversity in geographic location, size, and model of health care delivery. Each
of the jails had experienced at least one suicide in custody in the two years
leading up to the study, and two of the jails experienced a suicide during the
study period. Figure 1 below describes basic site characteristics.16

Study activities
Vera’s researchers engaged in the following activities while completing
this study.
››

4

 dministrative document and policy review. Researchers
A
requested and reviewed a variety of administrative documents
to better understand the jails’ responses to suicide and self-harm.
These included policies related to suicide prevention and response,
staff training, staff support, and review processes; training
materials; and anonymized investigative reports and mortality
reviews for the most recent suicide in custody. In total, Vera
reviewed 85 documents. Policies were compared to review-process
standards recommended by the American Correctional Association
(ACA) and the National Commission on Correctional Health Care
(NCCHC).17

Vera Institute of Justice

››

 ite visits and interviews with jail leadership and staff. Between
S
April and June 2018, Vera visited each study site and conducted a
total of 42 interviews with 56 people, including leadership (n = 32),
staff from health care (n = 26) and corrections/custody (n = 20),
legal counsel (n = 3), and internal affairs and investigation team
members (n = 7). (A complete list of interview participants can be
found in the Appendix on page 29.) Interviewee recruitment and
scheduling was facilitated by corrections leadership at each jail.
Interviews were conducted by one or two Vera researchers using a
semi-structured interview guide with questions exploring the issue
of suicide and self-harm at the jail, the types of review processes
currently in place to respond to suicide and self-harm, staff
training, relationships between corrections and health care staff,
staff support, and perspectives on the feasibility of implementing
sentinel event reviews.18
A team of four Vera researchers analyzed the interview
transcripts using Dedoose, an application that allows researchers
to organize, analyze, and identify major themes in qualitative data.19
The team reviewed transcripts and, through an iterative process
during regular team meetings, defined a set of codes to capture the
themes of the interviews. Once a complete code list was developed,
researchers coded all interviews, with 10 percent of the interviews
double coded by a second researcher to ensure reliability; coding
discrepancies were subsequently resolved through consensus
discussions. Researchers then reviewed the coded interviews to
develop consensus around the key themes and findings from the
interview data.

››

 egal landscape analysis. With pro bono assistance from attorneys
L
at the law firm Clifford Chance, Vera researchers conducted a
legal review of the four study jurisdictions, identifying potential
facilitators or barriers to conducting sentinel event reviews.
Specifically, Vera researchers analyzed the legal landscape of
liability, discovery, and public record requests in each jurisdiction.

Preventing Suicide and Self-Harm in Jail: A Sentinel Events Approach

5

Figure 1

Characteristics of sentinel event study sites
2015 jail
population

2015 jail
admissions

2015 county
incarceration rate
(per 100,000)

Mid-Atlantic

803

7,933

141

MSO

Northeast

1,183

5,634

109

PCSO

South

2,528

37,931

427

SCDS

Northwest

834

19,521

259

Site

Region

MCDOC

Source: Vera Institute of Justice, “Incarceration Trends,” https://perma.cc/WS5A-DRUP (accessed March 12, 2019).

Jails’ current responses
to suicide and self-harm

J

ails are constitutionally required to provide adequate health care to
people in their custody. The Supreme Court has held that evidence of
“deliberate indifference” to the serious medical needs of a person who
is incarcerated constitutes a violation of the cruel and unusual punishment
clause of the Eighth Amendment.20 In light of this mandate, accrediting
bodies such as the NCCHC and the ACA have developed minimum health
care standards for people who are incarcerated in the United States. These
standards are voluntary and not tied to funding, but they remain the most
widely used guidelines for ensuring quality health care delivery. Three of the
four jails in the study were accredited by the NCCHC and/or ACA.21 (See
“National standards on suicide prevention in jail” at page 7.)
The four jails in this study are notable for their suicide prevention
efforts. Each of the jails has a suicide prevention plan detailed in its
policies, as well as other written policies that, taken together, address
the areas consistent with NCCHC standards for a suicide prevention
program. In particular, it is notable that all of the jails studied conduct
clinical mortality reviews following deaths from suicide, something that
the majority of jails (63 percent) in the United States do not do following

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Vera Institute of Justice

National standards on suicide prevention in jail
NCCHC standards are the most widely used guidelines for health
care delivery in jails. These standards include both clinical and
nonclinical practices to identify people who are at risk of suicide,
develop treatment plans, and identify process improvements.
NCCHC standards explicitly delineate 11 key components
necessary for a comprehensive suicide prevention program:

›› an administrative review assessing the correctional
and emergency response;

›› a clinical mortality review answering three questions:

1.	 training;
2.	 identification;
3.	 referral;
4.	 evaluation;
5.	 treatment;
6.	 housing and monitoring;
7.	 communication;
8.	 intervention;
9.	 notification;
10.	 review (see below); and
11.	 debriefing.

a	

Recommended review processes. NCCHC’s standards
recommend three distinct reviews following each death in
custody in order to identify areas where facility operations,
policies, and procedures can be improved. These reviews are:

(1) could the medical response at the time of death
be improved?; (2) is there any way to improve patient
care?; and (3) was an earlier intervention possible?;
and

›› a psychological autopsy if the death is by suicide

(a reconstruction of the individual’s life and factors
that may have contributed to death, conducted by a
qualified mental health professional).a

Even with such standards in place, the NCCHC provides
little guidance on how to implement the various aspects
of a suicide prevention program. Policies and practices
therefore look markedly different across the jails and, in fact,
research suggests that only 20 percent of jails have a suicide
prevention program that covers all key components.b

NCCHC, Standards for Health Services in Jails (Chicago: NCCHC, 2014).

b	 

Lindsay M. Hayes, “Suicide Prevention in Correctional Facilities: Reflections and Next Steps,” International Journal of Law and Psychiatry 36, no. 3-4 (2013), 188194; and Lindsay M. Hayes, National Study of Jail Suicide: 20 Years Later (Washington, DC: U.S. Department of Justice, National Institute of Corrections, 2010),
https://perma.cc/9GXD-LMCY.

suicides in custody. (See “National standards on suicide prevention in jail”
at page 7 for key questions asked and answered in a clinical mortality
review.) These mortality reviews exist on top of other review processes
that are in place—some related to specific incidents and some focused
on ongoing quality improvement. MSO, for example, has established a
monthly, multidisciplinary suicide review committee. The committee
reviews suicides, suicide attempts, and self-harm every month whether
or not there is a specific incident to discuss. At MCDOC, administrative
staff, including corrections leadership and the mental health director, meet
weekly to review incidents of suicide and self-harm, if any, as well as other
incidents related to custody, housing, or health. Other sites also convene
staff for quality improvement meetings on a monthly or quarterly basis.
As noted above, however, the NCCHC and ACA offer little practical
guidance on how to implement the various aspects of a comprehensive
suicide prevention program. The result is that not only do policies and
practices differ widely across sites, but also that jails lack direction on what

Preventing Suicide and Self-Harm in Jail: A Sentinel Events Approach

7

robust practice looks like. Vera’s policy review and interviews revealed, for
example, that the jails did not include stakeholders from all staffing levels
in their review processes, had limited mechanisms for communicating
the findings of reviews back to staff, and did not consistently review
incidents of nonlethal self-harm. Some of the reasons for these gaps will
be discussed in the following sections of the report. They point to the
challenges as well as the potential for an all-stakeholder, nonblaming, and
forward-looking examination of the errors that occur when a person dies
from suicide in jail.

Key recommendations: Responses to suicide and self-harm
››

››

a

8

 evelop suicide prevention plans consistent
D
with national standards. Even jails that are not
accredited can follow guidance available from the
NCCHC or the ACA to develop suicide prevention
plans that address the 11 key components of robust
suicide prevention programs.
 eek out guidance on conducting robust
S
reviews. The health care and criminal justice
fields have helpful guidance on how to implement
an all-stakeholder, nonblaming review process in
the aftermath of a death.a This practical guidance

provides concrete steps to take and information
on how to overcome implementation challenges.
››

 onsistently review incidents of nonlethal
C
self-harm. Most reviews focus on suicide, and
sometimes suicide attempts, with less clear
criteria on when cases of self-harm warrant
a review. Given the prevalence of self-harm
compared to less frequent incidents of suicide,
this may be a missed opportunity to strengthen
practices and policies to prevent suicide and selfharm on a more regular basis.

 ope and Delany-Brumsey, Creating a Culture of Safety, 2016; James M. Doyle, “Learning from Error in the Criminal Justice
P
System: Sentinel Event Reviews,” in Mending Justice: Sentinel Event Reviews (Washington, DC: U.S. Department of Justice,
National Institute of Justice, 2014), 3-19, https://perma.cc/B5VT-G76W; The Joint Commission, Root Cause Analysis in Health
Care: Tools and Techniques, Fifth Edition (Oak Brook, IL: The Joint Commission, 2015); and Katharine Browning, Thomas
Feucht, Nancy Ritter et al., Paving the Way: Lessons Learned in Sentinel Event Reviews (Washington, DC: National Institute of
Justice, 2015), https://perma.cc/Q8HK-CFYH. Also see guidance from expert Lindsay M. Hayes collected at https://perma.
cc/D49E-ZB3R.

Vera Institute of Justice

Creating the conditions for
sentinel event reviews

A

t the time of this study, each of the four jails was already taking
important steps to prevent incidents of suicide and self-harm from
occurring and to respond comprehensively when an incident did
occur. At the same time, Vera found variability across the sites in terms
of readiness to mobilize the “routine, culture-changing practice” that is at
the heart of the sentinel event review process.22 Four key themes emerged
in the interviews as being critical to the success of future sentinel event
reviews around jail suicide and self-harm: the model of health care delivery,
the nature of collaboration and communication, the organizational culture,
and the legal landscape.

Health care delivery model
Although all jails share the same constitutional requirement to provide
health care to people in their custody, they can do so in different ways.
Indeed, since jails are located within counties that have wide variation
in size and resources, there are also significant differences in how the
government decides to deliver health care in a county jail and what services
it provides. An increasing number of jails contract with vendors to
provide at least some health care services. In New York State, for example,
only 16 percent of jails use a public provider such as a county hospital or
department of health to provide health services, while the remaining 84
percent contract with either private local providers or a correctional health
care firm.23 In Virginia, 89 percent of jails use vendors to provide at least
some health care, while the remaining 11 percent of jails deliver services
through directly employed staff (i.e., “in-house”).24 The jails in this study
have a variety of organizational models, as demonstrated in Figure 2 at
page 10. Further, with the exception of MSO, each of the jails has recently
experienced a transition in its health care arrangements.

Preventing Suicide and Self-Harm in Jail: A Sentinel Events Approach

9

Figure 2

Health care organizational models
Site

Organizational model

Explanation

Recent transition

MCDOC

Contracted out

Jail procures all health services (physical
and mental health) from
a single, private vendor.

Changed contracted
providers (2016).

MSO

Hybrid of in-house and
contract providers

Jail provides the majority of health
care services through a private vendor.
However, some mental health staff are
employed through the sheriff’s office.

N/A

PCSO

In-house

Jail provides all services using staff
employed by the sheriff’s office.

Brought services in-house
after a period of contracting
them out to a private vendor
(2014).

SCDS

Hybrid of in-house and
contract providers

Jail provides physical health care
through a contracted private vendor.
Mental health services are provided
through a private vendor in collaboration
with in-house positions, funded by a
partnering county agency (the regional
behavioral health organization).

Contracted with a private
vendor for the first time after
a history of providing services
in-house (2015).

It was clear from this study that the choices these agencies make around
health care have implications for institutional practices and working relationships.
These, in turn, can impact the feasibility of bringing stakeholders together in a
nonblaming review process.
There are multiple reasons a county may decide to outsource health care.
Private vendors can provide access to greater expertise, allow for greater budget
predictability and financial risk sharing, and free up jail administrators from the
routine activities of running a health system.25 SCDS, for example, had been unable
to provide 24-hour medical coverage at the jail until it started contracting with
a private vendor. In talking with administrators about the rationale behind their
decision to procure an outside vendor, a health services administrator noted that
they had been unsatisfied with the quality of care being provided through the
sheriff’s office and that “it became very evident that corrections people could not run
a health care organization.” Changing to a private vendor, he reported, had improved
the quality of care in the jail and allowed the agency to move from being primarily
“reactive” to “proactive.” Leadership at MCDOC also noted improvements as a result
of finding a different private vendor—better, more accessible care, and electronic
medical records that allow for improved continuity of care across providers in the
jail (and across jail stays for people who recidivate).

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Vera Institute of Justice

Even as private vendors can create more efficiencies in medical care, it is also
true that this arrangement adds complexity when thinking about sentinel event
reviews and responses to suicide and self-harm. This complexity occurs on at
least three levels, by potentially introducing different systems of accountability,
different training requirements, and different review processes.
For the three jails in this study that have a hybrid or fully contracted out
model of health care delivery, the county jail has to manage relationships with
outside organizations and integrate employees with different management
structures. In one case, the process of building these relationships has been
especially fraught because of a widely held perception that the incoming private
vendor led to the elimination of union positions; this created a “very difficult
transition” that was still in process at the time of this study, according to a jail
administrator. But even in two sites where relationships were perceived as being
quite good between the jail administration and the health care vendor, leadership
and staff noted challenges. Staff at one site described how they had worked
hard to create balanced and collaborative working relationships. Even so, the
administrator of that jail noted it remained complicated:
I struggle with it because I would like it to be one or the other [i.e., all
sheriff’s office employees or all contracted out]. . . . You would hope it
would be tightly organized or the messaging would be the same and I
think that having that two different kinds of operations can be a challenge
sometimes. . . . At the end of the day it works out okay, it’s just the
bifurcated approach sometimes can be challenging.
These challenges were not reported at PCSO, where all staff are employees in the
sheriff’s office. Instead, interview participants discussed the benefits of having a
single hierarchy and point of accountability. “We do a pretty good job,” a PCSO
health care staff member reflected. “I think a lot of it is the fact that we’re sheriff’s
office employees. . . . We all have the same resources as far as care and self-care go.
We also have a camaraderie that you wouldn’t have perhaps with an agency staff
for medical or even detention. . . . We’re all a big family here. And there’s not a lot
of issues with that.”26
Different systems of accountability can also result in different training
requirements (around suicide and self-harm or more generally) for health and
corrections staff. For example, MCDOC and SCDS contract with the same large
correctional health care provider that has developed its own set of training
materials that health care staff complete independently, online. This goes against
expert guidance recommending that health and corrections staff should receive
training on suicide prevention together. As jail suicide expert Lindsay Hayes notes,

Preventing Suicide and Self-Harm in Jail: A Sentinel Events Approach

11

“the topic of suicide prevention is one that is best provided in a live, interactive
environment amongst correctional, mental health, and medical personnel. Suicide
prevention is all about collaboration. . . .”27
Finally, when at least part of a jail’s health care delivery is outsourced, the review
processes undertaken by agencies and vendors after critical incidents might occur
entirely independent of each other. This is the case in MCDOC and SCDS, where
health care is contracted out and the private vendor conducts independent mortality
reviews at the corporate level, but does not share the results back to the jail. These
issues in and of themselves do not mean that quality training and review processes
are not in place. But it is clear that multiple strands of management and the presence
of different reporting structures can create added complexity for developing robust
review processes when incidents of suicide and self-harm occur in the jail.

Key recommendations: Responses to suicide and self-harm
››

T raining on suicide and self-harm prevention
should include corrections and health staff
together—in person—to foster collaboration and
learning across disciplines.

››

 articularly for jails that contract out their
P
health care delivery or have multiple agencies
providing health care, review processes should
be consolidated and outcomes should be
communicated to both corrections and health
leadership and staff.

Collaboration and communication
Strong collaboration and effective communication are vital to create the
conditions that prevent incidents of suicide and self-harm and can also foster
space for sentinel event reviews and corrective action when an event occurs.28
At the same time, collaboration and communication within a jail are not easily
written as policy directives. Two themes emerged through Vera’s study as
especially relevant in this regard: (1) the relationship between corrections staff
and health staff; and (2) the extent to which information is communicated across
disciplines, as well as both up and down the chain of command.
Health care staff and leadership at each of the jails described being reliant on
corrections staff for suicide prevention, as corrections officers have the most regular
contact with people incarcerated in the facility. Multiple clinical staff described
corrections officers as “our eyes and ears,” noting that corrections officers’ close
proximity and more frequent contact allows them to “pick up any subtle changes that
are happening” with people in their custody. One nurse reflected:

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Vera Institute of Justice

We rely on them. They rely on us. That is the only way to function
within a correction facility. Because they’re the ones with eyes on.
They see the behavior day after day after day. The report to us if
they have any concerns. They watch them if they don’t eat. They
report to us. That relationship between detention and medical staff
is essential. . . . It’s like a symbiotic relationship.
The necessary collaboration across corrections and health does not
mean that such collaboration is always easy. Staff from both corrections
and health were cognizant that they had different roles, different training
and experience, and different professional cultures that sometimes put
them at odds with each other. As one corrections official remarked:
There is always going to be challenges because you have two
populations here of employees. You have more of the human
services piece. . . . And then there are the more conservative
paramilitary corrections piece. There have been times when they
were brought close together and sort of their philosophy was sort
of brought close together, to the middle. There are times when they
are very far apart, and that can be a challenge.
These different subcultures can create conflict at times, particularly when
there is a sense that one side is not pulling its weight. Even so, staff largely
described a relationship of respect, recognizing they are, as scholars
have described it, “united in mutual dependence” as they work across the
treatment and custody divide.29 This interdependence is at once basic to jails
and crucial to prevent and respond to incidents of suicide and self-harm.
The nature and extent of communication—both across disciplines and
within the hierarchy of the jail—emerged as a key theme in thinking about
the necessary conditions for a nonblaming, all-stakeholder review process.
Much of the communication occurs through the formal chain of command,
with information and directives pushed down and feedback provided back
up through the existing hierarchy. The jails in this study use a wide range of
approaches to communicate information in verbal or written from, including
through informal conversations, roll calls, shift reports, regular team
meetings, and formal review processes. This wide range of communications
strategies is necessary given the practicalities of working in a jail, including
shiftwork and the lack of electronic communication for corrections officers
in many jails. For the most part, the strategies being used prove effective and

Preventing Suicide and Self-Harm in Jail: A Sentinel Events Approach

13

are in line with the spirit of collaboration discussed above. At the same time,
the traditional default to a top-down communication style presents particular
challenges in the context of more formal review processes for critical
incidents. The primary theme reflected across sites when discussing existing
review processes was that line staff are generally not included in the reviews
and that there are few or no mechanisms for communicating the outcomes
or plans for corrective action.
Staff from different jails and across disciplines (corrections, mental
health, nursing) informed Vera that they did not receive information
about what was found through review processes. A charge nurse at
one jail relayed how the details she received were “just through the
grapevine . . . there’s no formal dissemination that I’m aware of, of any
of that information.” At another jail, a mental health clinician reflected
on a specific death from suicide and recalled how the conclusions
from the mortality review and other review processes had never been
communicated to the clinicians. “We didn’t get anything. . . . I think
it’s fantastic that there’s so many multidisciplinary teams involved in
everything that happens in here, but then information gets lost all the time.
. . . We have people who are doing the groundwork and not being included,
which can be frustrating.” The lack of review processes that include all
stakeholders and the absence of a feedback loop is related at least in part
to the fear of litigation. (See “Legal landscape” at page 21.) From Vera’s
interviews, it is clear that jails struggle with communicating the results
of review processes and that there is room for improvement around
developing truly collaborative reviews.

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Key recommendations: Communication and collaboration
››

 orrections and health leadership should work
C
together to institute review processes that include
stakeholders from all disciplines and levels,
with a focus on disseminating findings and
recommendations to staff who are in the position
to implement corrective actions. Including line
staff who work directly with people who are
incarcerated, such as nurses, mental health and
social workers, and corrections officers, may help
identify system weaknesses that would otherwise
be overlooked.

››

 eview processes for suicide and self-harm must
R
establish clear feedback loops to communicate
findings and recommendations to all staff.
Increasing transparency in the review process
can also facilitate understanding of the full
purpose of the reviews, which in turn can
encourage candor during the informationgathering phase.

Organizational culture
Beyond everyday mechanisms for collaboration and communication
within a jail, the broader organizational culture of the jail itself plays a
critical role in the success of sentinel event reviews. At their core, sentinel
event reviews require a culture that is committed to addressing system
weaknesses in order to prevent future adverse outcomes, instead of a
culture of blame that is fixated on identifying bad apples.
Organizational culture is a multidimensional concept that has been
described and understood in diverse ways, but is widely believed to be
linked to organizational successes and failures.30 It includes attributes
such as the nature of, and people’s confidence in, leadership; qualities of
relationships and collaboration; core values and beliefs among staff; capacity
for and orientation towards individual and organizational learning; and
more.31 Three aspects of organizational culture emerged as particularly
relevant to creating the conditions for sentinel event reviews of jail suicide
and self-harm: the way blame operates, openness or resistance to change, and
attitudes around mental health and suicide prevention efforts.

Preventing Suicide and Self-Harm in Jail: A Sentinel Events Approach

15

Promoting wellness for corrections and health staff in jails
A critical, but sometimes overlooked, component of jail suicide
and self-harm is the impact of these incidents on frontline
corrections and health staff. Corrections officers often
experience intense stress while on duty, which places them
at increased risk for poor psychological and physical wellbeing; studies have found that rates of suicide for corrections
officers exceed those of the general public and police officers
by more than two times.a Supporting staff wellness in jail and
correctional settings does not only benefit individual staff
members, but should also be considered as an organizational
goal to improve safety for people who are incarcerated and
for staff as a whole to prevent burnout and reduce turnover. In
Vera’s study, site visits and interviews revealed some common
approaches to promoting staff wellness and providing
support to staff involved in corrections deaths, suicides, and
other critical incidents.

a

››

Debriefing meetings. Following critical incidents
such as a suicide, the majority of the study sites
held debriefings to ensure the well-being of all staff
involved by processing thoughts and feelings.b
However, in some cases not all staff who may be
emotionally affected are included in debriefings and
debriefs were described as “minimal.” Other mental
health resources may be provided to staff after such
a debriefing for anyone still in need of assistance.

››

 mployee Assistance Programs (EAPs). All study
E
sites had EAPs available for their employees, which
can be utilized for counseling services (e.g., six free
therapy sessions) following a traumatic event at
work. EAPs can also facilitate paid time off for staff
after they are involved in a traumatic incident.

››

 ritical Incident Stress Management (CISM)
C
and peer support teams. CISM is a multifaceted
approach to offer short-term support, debriefing,
counseling, and referrals to individuals following
critical incidents that has been adapted and

implemented in many different settings.c A key
element of CISM is having a trained team, usually
composed primarily of peers, deliver these supports.
Three of the four study sites had a CISM team or
a similar peer support initiative on site. The fourth
made corrections officers aware of a peer support
phone line for all law enforcement and corrections
officers in the state.
However, although jails can make supportive resources
available, staff may not be utilizing them. This was noted by
staff at the jails Vera studied. Others expressed feelings that,
although resources may be available, institutions could still
do more to support staff. Vera’s interviews with staff revealed
common explanations for why resources go underutilized:
(1) often staff are unaware of available resources; (2) staff
are hesitant and uncomfortable reaching out for help; (3)
staff lack faith in resources; (4) staff claim to be unaffected
by critical events because deaths in jails are somewhat
commonplace; (5) staff feel the institution and culture is
quick to move on; and (6) staff turn to alternative supports.
It is clear that there is a need for institutions to promote
utilization of resources and ensure that staff have the
time and space they need to process distressing emotions
following critical incidents. Leadership in some of the sites
made a concerted effort to normalize emotional responses
to critical incidents and attempted to foster a supportive
environment by promoting destigmatizing attitudes toward
seeking help. These positive messages can be effective,
starting from the top down, in helping staff at all levels
feel comfortable seeking support. Further, institutions may
consider implementing policies that require all staff involved
in critical incidents—both scene responders and treatment
team members—to see a provided external counselor for an
initial processing and evaluation session. Doing so could
help reduce shame associated with seeking help, ensure
all staff have a personal space to process any emotional
reactions, and provide an avenue to further follow-up
treatment if needed.

New Jersey Police Suicide Task Force, New Jersey Police Suicide Task Force Report (Trenton, NJ: New Jersey Police Suicide Task Force, 2009), https://perma.cc/

LT5S-6KV3; and Steven J. Stack and Olga Tsoudis, “Suicide Risk among Correctional Officers: A Logistic Regression Analysis,” Archives of Suicide Research 3, no. 3
(1997), 183-186.
b

Debriefing is one of the NCCHC’s key components of a suicide prevention plan. Under these standards, debriefings should include the opportunity for staff to ex-

press their thoughts and feelings, develop an understanding of stress response symptoms to critical incidents, and develop effective coping strategies. Debriefings
are not intended to feel forced or confrontational.
c

George S. Everly, Raymond B. Flannery, and Jeffrey T. Mitchell, “Critical Incident Stress Management (CISM): A Statistical Review of the Literature,” Aggression

and Violent Behavior 5, no. 1 (2000), 23-40; Richard L. Levenson Jr., “Prevention of Traumatic Stress in Law Enforcement Personnel: A Cursory Look at the Roles of
Peer Support and Critical Incident Stress Management,” Forensic Examiner 16, no. 3 (2007), 16-19; and Abigail S. Malcolm, Jessica Seaton, Aimee Perera et al.,
“Critical Incident Stress Debriefing and Law Enforcement: An Evaluative Review,” Brief Treatment and Crisis Intervention 5, no. 3 (2005), 261-278.

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Culture of blame
In the four jails Vera studied, many staff described a culture of passing
around and placing blame on individual people. Corrections officers in one
jail explained that because all their activities are subject to investigation
and scrutiny, they are careful to document all their checks and rounds
and to involve health staff to pass off responsibility. This was summarized
colloquially as the “cover your ass” mentality:
I think that there’s just a fear of, “Oh, I should have done this check.
I missed a check, and this happened, you know, so I’m afraid to
lose my job now.” So, it’s the, you talked about blame earlier, I think
that’s a lot of the apprehension of people to say this is what I actually
did, as opposed to what maybe I should have done.
In another jail, corrections officers were characterized as wanting to
keep their heads down, complete their shifts, and get out:
That’s usually how most of the officers go about their day. And so,
when their name comes up, they’re like, “Well, wait, why?” When I’ve
asked people to come in for a debrief for, you know, peer support,
they are like “Why? What did I do?” I’m like, “You didn’t do anything.
You are just a part of the incident the other night.” He’s like, “Oh,
well, I’m—” you know, the first thing he says is, “I’m good. I’m fine.”
Across all four jails, the culture of blame was identified as a key barrier
to the implementation of truly nonblaming review processes. Many
staff described that they would be very skeptical if they were invited or
instructed to participate in a review. As one lieutenant remarked:
I think it would be tough. It would be very tough. The nonblaming
part would be tough because it would feel like someone would
always be trying to justify their actions the whole time.
This was elaborated on by his colleague:
I think they are going to go into it with a certain mindset of not
saying anything at all, because even if it were a completely, you
know, we’ll call it a “consequence free environment” or “safe place”

Preventing Suicide and Self-Harm in Jail: A Sentinel Events Approach

17

or whatever you want to call it, where this information could be
said without disciplinary action, there aren’t many people that
would believe that. They would still see it as . . . you can tell them,
you can put it in writing, you can do anything, and they are still
going to be like, they’re not going to take the risk.
However, some staff were more optimistic about the feasibility of
sentinel event reviews and felt that if leadership could actually demonstrate
to line staff that the review process is not designed to single out and
discipline individual staff, as opposed to just telling them this, it might
be possible to overcome the prevailing expectation of blame and fear of
disciplinary action. As one said:
In my mind you have to do it and then we have to prove it to them.
. . . Telling our staff . . . “Nobody’s going to get in trouble, we need
you to be honest”. . . . If you offered this up to most staff [they
would say], “I’m good, I’m out,” because, because of that culture . . .
you have to get it in there and you have to demonstrate it before.
At PCSO, one interviewee described how the participation, buy-in, and
discussions in their existing review processes had improved over the years
and attributed this to leadership setting the tone:
I think the current sheriff is very much about just open and
honest communication, I think him, as the leader, is what makes
everybody comfortable doing that. He understands that, you
know, there are such things as human error and mistakes and he
also is big on if it wasn’t a mistake and it’s some sort of policy and
procedure that it has to be corrected and the way to do that is to
acknowledge it, to accept what happened and why it happened, and
then make sure it doesn’t happen again.

Attitudes toward change
Attitudes toward change emerged as another important aspect of
organizational culture when considering the implementation of sentinel
event reviews. Many staff across the four jails characterized their colleagues
and workplace as resistant to change. Jail leadership at one jail expressed:

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Vera Institute of Justice

I have a lot of more senior officers who are okay with the
monotony of day to day. They don’t like change. You know, if you
were to tell them they had to . . . start using a blue pen instead of
a black pen they might . . . they might quit or retire. So change
definitely does not go over well in this environment.
And a corrections official at a different jail elaborated further:
Change here is brutal. It’s just . . . nobody likes change in the
real world, but here especially, it is very difficult, change. So, it’s
a challenge. When, you know, when the administration comes
and says, “Okay. We’re going to do something different and we’re
going to, you know, use a vendor or use an outside [provider],” the
immediate response is going to be difficult because people feel like
their job is in jeopardy.
Despite the widespread aversion to change, some staff were still able to
cite a few specific examples of corrective actions taken to prevent suicide
and self-harm within their jails. Most of these were tangible, observable
aspects of suicide prevention, such as physical changes to cells or increased
staffing devoted to mental health screening, assessment, or substance
withdrawal management. Many of these corrective actions were direct
outcomes of an institutional review process, suicide review, or mortality
review. At MSO, for example, a standing suicide review committee that
meets monthly has allowed staff and leadership to take a more preventive
approach to suicide and self-harm rather than reacting only when someone
dies by suicide; for example, as a result of these monthly meetings they
have made changes to increase visibility into cells. Corrective action and
culture change can stem from internal changes—such as new leadership
or transitions in health care delivery—as well as the introduction of
external supports. These could include bringing back new ideas and good
practices from conferences or professional networks, or securing technical
assistance in the form of suicide prevention experts or NCCHC reviews.
For MCDOC, a recent change in corrections leadership brought fresh
eyes to identifying and addressing gaps in suicide prevention. This led
to a transition to a new health care provider; the allocation of resources
to suicide prevention training, staffing, and physical cell improvements;
and proactive engagement with staff around changes. Regardless of their
source and approach, these examples demonstrate the possibilities for

Preventing Suicide and Self-Harm in Jail: A Sentinel Events Approach

19

shifting staff and organizations from deeply ingrained resistance to change to
a position of readiness.

Beliefs around mental health
Another important aspect of organizational culture within jails that is
especially relevant to sentinel event reviews pertains to beliefs around
mental health, suicide, and self-harm. Beliefs and attitudes about—as well as
approaches to and resources for mental health—have shifted in significant
ways within the corrections field and these specific jails. Staff with long
careers in corrections have been able to observe these changes over time. The
mental health director at one jail remarked, “It’s so different now. It used to
be mental health, really, didn’t have much of a seat at the table, and now I feel
like we have, like, the biggest seat at the table.” This growing recognition of the
mental health needs of people in jail was commented on by many other staff,
who also noted their jail’s efforts to improve mental health care.
Despite this progress, Vera found that some staff still believe that not all
instances of suicide in jails are preventable. For example, although leadership
at one jail put out a call to action for their staff to “collectively work together to
figure out how to prevent this, because it’s preventable,” a corrections officer at
the same jail held the belief that, “If somebody wants to kill themselves, they’re
going to find a way to do it.” At another jail, staff also felt that a recent suicide
couldn’t have been predicted and thus couldn’t have been prevented:
You just never know. Now, unfortunately, I would think that a lot of
people that truly want to commit suicide, they won’t tell you about it.
They’ll seem as normal as you or I, and then they’ll just do it. And, in
those cases, you just can’t prevent it . . . [when the] person gives you no
warning whatsoever. There’s no way to improve that.
The fact that suicide is the leading cause of death in jails is a challenging
reality for both line staff and leadership. For suicide prevention efforts to be
effective, staff must feel confident they have the necessary knowledge and
resources to identify and intervene in cases of potential suicide. Attitudes
regarding the preventability of suicide may also determine whether jails
consider sentinel event reviews to be a useful tool.
Because jails are often large organizations, shaped by strict command and
control structures and containing multiple subcultures among health and
corrections staff, the question of how to influence organizational culture within
them is complex. Leadership at one jail remarked, “it takes a couple years for

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Key recommendations: Organizational culture
››

 ncourage leadership to actively demonstrate its
E
commitment to focusing on system weaknesses
and addressing root causes, not individual errors
and staff; this will foster trust and candor during
review processes.

››

 uring the review process, build in opportunities
D
for review team members to express their
misgivings about the process and work through
conflicts. a

a	

››

 se trainings on mental health, suicide, and
U
self-harm to develop capacity among staff and
overcome the belief that some suicides are not
preventable.

››

 ighlight positive changes that result from review
H
processes to encourage openness to change.

Katharine Browning, Thomas Feucht, Nancy Ritter et al., Paving the Way: Lessons Learned in Sentinel Event Reviews (Washington, DC:
National Institute of Justice, 2015), https://perma.cc/Q8HK-CFYH.

you to kind of make cultural changes.” Across the four jails that Vera studied,
attitudes toward blame, change, and mental health and suicide prevention
emerged as a few of the key aspects of organizational culture that will
impact the feasibility of more robust review processes for suicide and serious
incidents of self-harm. Encouragingly, the highest levels of corrections
leadership recognized how important their role is in fostering change and
agreed that a proactive approach is critical to shifting attitudes, obtaining buyin, and successfully implementing changes to improve practice around suicide
and self-harm.

Legal landscape
The barriers and facilitators to sentinel event reviews described above
operate largely within the jail itself. But the feasibility of conducting
sentinel event reviews also depends on the complex legal landscape in
each jurisdiction. Discussions about confidentiality and calculations
around risk and liability are omnipresent in the criminal justice system
and likely heightened when thinking about incidents of suicide and selfharm. Vera’s analysis of the legal landscape—as well as the interviews at
each jail with health and corrections staff, internal investigations, and
legal stakeholders—focused on four key issues that jurisdictions will have
to grapple with as they consider implementing sentinel event reviews:
liability, discovery, public records requests, and confidentiality.

Liability
Incidents of suicide and serious self-harm in jails may give rise to legal
liability for jails and may draw particular scrutiny because courts have

Preventing Suicide and Self-Harm in Jail: A Sentinel Events Approach

21

already established liability under certain circumstances.32 Lawsuits related
to incidents of suicide and serious self-harm may be based on allegations
that the jail or a specific staff member deprived an incarcerated person of
his or her constitutional or statutory rights or that the jail failed to act with
reasonable care toward the people in its custody.33
It is important to note that conducting a sentinel event review does not
give rise to additional liability itself, but the review process could increase
litigation exposure by aggregating details about the incident into documents
that could ultimately be obtained either by plaintiffs (through discovery
during litigation) or the public (through freedom of information requests).
In the jails Vera studied, the fear of liability and litigation was intense for
many staff, who felt that litigation was inevitable in the event of a death in
custody. This emerged as a potential barrier for robust review processes. When
asked about current review processes and the possibility for sentinel event
reviews, an internal affairs and investigations team member revealed he is
reluctant to name names and identify areas for improvement in writing:	
I’m totally with you and I think we should do that and I get the
nonblaming, but when we say, “Hey,” and somewhere in writing,
“This policy says 30-minute rounds but it wasn’t done for 45
minutes,” we’re just opening ourselves up. You don’t have to have a
name associated with it. The report doesn’t have to be critical. It can
be, “Hey, we need to do this better,” and as soon as we say that in
writing somewhere, it costs us a lot of money.
For corrections leadership who are responsible for implementing
review processes in their jails, concerns about liability and litigation factor
into their hesitation to widen the circle of participants involved in reviews
and contribute to gaps in communicating the findings from reviews
to facilitate corrective action. A legal counsel at one jail noted it was a
“tremendous challenge” to balance sharing and protecting information. One
top official explained that he tries to “find that sweet spot” where they can
“cover what the lawyers are concerned about but also get information off
to the appropriate people to make the right changes.”

Discovery
As discussed above, although sentinel event reviews do not themselves
give rise to liability against a jail or individual employees, documents

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produced from a sentinel event review could be obtained by plaintiffs
through discovery during litigation unless they are deemed to be
privileged in some way. Two common privileges are likely inapplicable:
attorney-client privilege only protects communications between lawyers
and clients made in confidence to obtain legal advice (and does not protect
the underlying facts gathered in the communication) and work-product
privilege only protects information prepared by or for an attorney in
anticipation of litigation.34 Some states, however, have enacted privileges
that protect from discovery records pertaining to confidential internal
investigations (known as the “self-critical analysis privilege”) and/or
documents produced to inform the development of new policies (i.e.,
documents that are “pre-decisional” or related to the processes by which
policies are formed).35 Depending on the specific state statute, these types
of privileges for internal policy making may protect documents produced
during sentinel event reviews for suicide and self-harm in jails.36 In one of
the four states Vera studied (Washington), records, proceedings, and reports
from formal medical review boards and hospital quality improvement
committees—spaces and processes similar to those occurring in jails—
are considered to be privileged.37 Similarly, Massachusetts has codified a
medical peer review privilege, which protects the proceedings, reports,
and records of eligible committees that function to evaluate or improve the
quality of health care rendered by health care providers.38 Those interested
in protecting information collected by sentinel event review boards in
Washington, Massachusetts, and states with similar protections could
advocate to extend these statutory privileges to medical and health policy
review in jails.
In the other two states Vera studied, there are no such statutory privileges
that might be extended to protect the records of sentinel event reviews. The
New Jersey Supreme Court has held that the confidential investigative records
of a professional licensing board’s inquiry may be discoverable in a medical
malpractice case involving the physician at issue. The court set forth a threepart balancing test that takes into account whether the plaintiff could obtain
the information from other sources, the degree of harm plaintiff would suffer
without access to the records, and the potential for prejudice to the board’s
investigation.39 In Florida, medical committee meeting minutes and similar
review reports are now discoverable after a 2017 Florida Supreme Court
decision construing a voter-approved amendment to the state constitution to
allow patients a broad right of access to records relating to adverse medical
incidents.40 For PCSO in Florida, minutes from meetings held by its death and

Preventing Suicide and Self-Harm in Jail: A Sentinel Events Approach

23

serious injury board have been subpoenaed in previous lawsuits. However,
PCSO’s legal counsel believes that continuing with their existing review
process or, preferably, an even more robust sentinel event review process, is the
right thing to do from a liability perspective:
The advice I give all the time is the only wrong answer here is to
do nothing. You find a problem and you just identify it and then
do nothing, then you know it would be discoverable, it would be
admissible and, quite frankly, you know I kind of think it should
be. . . . As long as you do something in an attempt to address it and
identify it, then [it shows] . . . this is why we’re not deliberately
indifferent, we’re trying and this is what we uncovered and this is
what we did and you know we’re sorry yours was the guy that you
know brought this to light.
This sentiment encapsulates a key finding highlighted in Vera’s previous
analysis of the law in New York: the risks related to a sentinel event review
should be considered in proportion to the potentially greater “risks that
come with leaving problems undiscovered and unaddressed.”41 Indeed,
New Jersey and Massachusetts have similar laws to New York. In these
states, an agency violates its duty of care when there is foreseeable risk and
the agency fails to take reasonable steps to prevent the harm from coming
to pass.42 It can thus make good sense to proactively engage in sentinel
event reviews as a way to both avoid harm and contain liability.

Public records requests
Freedom of information laws provide the public with access to
government records and information, creating an important channel to
hold governments accountable. It should be expected that any information
pertaining to suicide and self-harm in jails, such as the outcomes of a
sentinel event review, will be of interest to the media and the general
public, and these laws are another way that internal documents from a
review could be made available.
At the state level, the provisions of freedom of information laws can
vary widely. Some states have enacted specific statutory exemption for
interagency or intra-agency communications pertaining to policymaking
within the government, so that frank and honest discourse about options is
not stifled by the threat of public disclosure.43 In Florida and Washington,

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however, no such exemptions exist, and SCDS staff expressed frustration
about public records requests. Internal affairs and investigations staff felt
“really reluctant” to put anything in writing about “what we could do better
in a suicide.” A health administrator shared:
[W]hen you go and say, “Hey, we could have done this better or we
could have done that better,” you are just opening yourself up for [a]
newspaper article, for claims filed over risk management lawsuits.
It really is not an environment that is conducive to being honest
about your performance.
Additional public scrutiny of a suicide or incident of serious self-harm is,
understandably, a potential concern for jail officials. However, the same
rationale used by PCSO in describing the tradeoff between having review
documents subpoenaed and not doing reviews arguably applies in the case
of public records requests: that is, demonstrating evidence of a thoughtful
and regular review process through engagement in sentinel event reviews
may lead to practices and protocols that prevent “deliberate indifference” to
the care of people who are incarcerated.44

Confidentiality
Finally, jails undertaking sentinel event reviews must consider issues that
arise around sharing confidential health information during the review
process. Sentinel event reviews usually aim to bring together stakeholders
of different disciplines and, sometimes, different agencies. However,
depending on how jails administer their health care and how sentinel event
review boards are organized, health information privacy laws may limit
access to personal health information—including information pertaining to
incidents of suicide and self-harm—for some review team members.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA)
governs how health care providers, health care plans, and health care clearing
houses (“covered entities”) use and disclose people’s identifiable protected
health information (PHI) and applies for 50 years following the date of a
person’s death.45 The HIPAA Privacy Rule provides safeguards to protect
the privacy of individuals’ personal health information, including that
covered entities cannot share PHI except as explicitly permitted or required
by the law.46 Additional federal or state laws and regulations providing
more stringent privacy protection also apply, especially related to mental

Preventing Suicide and Self-Harm in Jail: A Sentinel Events Approach

25

illness and substance use.47 With respect to HIPAA, there is some debate
about whether correctional institutions are considered covered entities
(and therefore must comply with HIPAA standards). One legal scholar
has cautioned that this determination is complicated and requires careful
analysis of the institution’s operations and model for delivering health care.48
HIPAA’s Privacy Rule does have an exception that allows for health
providers and other covered entities to share PHI with correctional
institutions having lawful custody of a person if it is necessary for (1) the
health and safety of the incarcerated person or other people in the facility;
or (2) the maintenance of safety, security, and good order of a facility.49 At
SCDS, which has a hybrid model of health care delivery with a contracted
private vendor, staff said that “the contract allows for the contractor to
share that mental health or medical information with detention services
[staff] upon request.” HIPAA’s Privacy Rule also has an exception that
allows for health providers and other covered entities to share PHI with
public health authorities (such as a local health department) for the purpose
of public health activities, including preventing injury and conducting
public health investigations.50 Therefore, correctional institutions may be
able to work with their local public health authorities to create a plan for
sharing PHI for sentinel event reviews.
In practice, considerations about confidentiality and HIPAA may prevent
some participants from having access to personal health information, but
should not prevent reviews from taking place at all. At one of the jails Vera
studied, stakeholders explained that for their current reviews:
The people that are in there are at the top of the . . . chain of
command, . . . they all are able to have access to the [medical] file for
this board review for this purpose. . . . For example, [legal] would get
the medical file, but training wouldn’t necessarily get the medical file.
. . . So, I can’t say that there is no [PHI] that is discussed, but it’s at the
highest level of people with the need to know based on the review,
and they get what they need to know and that’s it.
This follows an important principle of HIPAA, which instructs health
providers and other covered entities to take reasonable steps to limit the
use or disclosure of personal health information to the minimum amount
of information necessary to carry out the purpose of the disclosure.51
HIPAA also provides standards for de-identifying personal health
information, should sentinel event review boards choose to go this route.52

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Key recommendations: Legal
››

 o not be dissuaded from conducting reviews
D
because of concerns around sharing personal
health information. These issues may limit the
depth of information available to all review team
members, but should not prevent reviews from
taking place at all.

››

 ork with legal counsel to understand the
W
protections that exist in state law.

››

 hampion the value of a sentinel event review
C
process even in the face of liability, not only for
improving practices around suicide and selfharm—which is an important goal on its own—
but also as way to proactively avoid harm and
contain liability.

Conclusion

P

reventing and responding to incidents of suicide and self-harm must
continue to be urgent priorities for jails across the United States.
Several hundred people die of suicide in custody each year (372 in
2014), the majority of whom have not been convicted of crimes and often
die within days of arriving in jail (between 2000 and 2014, the median time
in jail before death from suicide was nine days).53 Thousands more engage in
acts of self-harm that can have serious consequences. It is critical to elevate
the acute health risks of jail and the national crisis of jail suicide and selfharm, particularly at a time when the public is paying more attention to local
jails and reform efforts.54 Despite the formidable obstacles, research and
guidance from experts demonstrate that it is possible to forestall suicides
in custody with a comprehensive suicide prevention program—one that
addresses regular training of all staff, screening and assessment for suicide
risk, communication procedures, housing commensurate with risk level,
reporting, and multidisciplinary review processes, among other factors.55
That so few jails nationally have the full continuum of comprehensive
suicide prevention services is startling given the data.
This research started from the perspective that review processes for
deaths in custody are all too often adversarial and that practitioners can
benefit from integrating an all-stakeholder, nonblaming, and forwardlooking error-review process. The success of sentinel event reviews in

Preventing Suicide and Self-Harm in Jail: A Sentinel Events Approach

27

other industries like medicine and aviation provides evidence that it is
possible to learn from error and to strengthen overall system reliability by
understanding the root causes of negative outcomes. Vera’s research suggests
that it is also possible in the criminal justice system, notwithstanding the
many challenges stakeholders may face when trying to implement such
reviews. The jails that participated in this study all have review processes
in place for critical incidents, but were also open to considering how their
current processes might be improved. This could be achieved by expanding
the types of staff included in reviews, for example, or making review findings
and recommendations transparent across their agencies.
To be sure, no two sentinel event review processes will look the same.
The results of this study suggest that the design and implementation of any
sentinel event review process will depend crucially on four key aspects
of the jail: how health care is delivered, the communication processes in
place, the organizational culture of the jail, and the legal landscape of the
state where the jail is located. Thankfully, there is emerging guidance in the
field to help jurisdictions walk through the range of factors they should
consider in designing a sentinel event review and implement the concrete
steps in the review process.56 Jails that adopt sentinel event reviews will
not only demonstrate leadership and commitment to advancing the field of
suicide and self-harm prevention, but will also help instill a new culture in
their facilities—one that promotes the safety and well-being of the people
in their custody, as well as those who work there. With the lives of people
who are incarcerated at stake, it is critical that more jails work to embrace
this approach and its ethic of shared responsibility.

28

Vera Institute of Justice

Appendix
List of interview participants
Site

Interview #

Leadership level

Role type

Role description

MCDOC

33

Leadership

Legal counsel

Senior deputy county
counsel

MCDOC

34

Leadership

Health

Director of nursing

MCDOC

35

Leadership

Health

Mental health director

MCDOC

36

Line

Corrections

Officer

MCDOC

36

Line

Corrections

Officer

MCDOC

37

Leadership

Health

Health services
administrator

MCDOC

38

Mid-level

Internal affairs and
investigations

Chief investigator,
internal affairs

MCDOC

38

Mid-level

Internal affairs and
investigations

Officer/investigator,
internal affairs

MCDOC

39

Leadership

Corrections

Chief of staff

MCDOC

40

Leadership

Corrections

Warden

MCDOC

41

Line

Health

Social worker

MCDOC

42

Leadership

Corrections

Operations captain

MSO

23

Leadership

Corrections

Superintendent

MSO

24

Leadership

Legal counsel

Chief legal counsel

MSO

25

Leadership

Corrections

Special sheriff

MSO

26

Leadership

Health

Health services
administrator

MSO

27

Leadership

Corrections

Assistant deputy
superintendent, policy
advisor

MSO

28

Leadership

Health

Mental health director

Preventing Suicide and Self-Harm in Jail: A Sentinel Events Approach

29

MSO

28

Leadership

Health

Doctor and CEO of
contract healthcare
provider

MSO

29

Leadership

Internal affairs and
investigations

Internal investigations
unit director

MSO

30

Line

Health

Medical clinician

MSO

30

Line

Health

Medical clinician

MSO

31

Mid-level

Corrections

Lieutenant

MSO

31

Mid-level

Corrections

Sergeant

PCSO

1

Leadership

Corrections

Colonel

PCSO

1

Leadership

Corrections

Major

PCSO

2

Line

Health

Licensed mental health
counselor

PCSO

3

Line

Health

Licensed mental health
counselor

PCSO

4

Leadership

Health

Nursing director

PCSO

5

Line

Health

Charge nurse

PCSO

6

Mid-level

Corrections

Sergeant

PCSO

7

Leadership

Health

Health services
administrator

PCSO

8

Leadership

Health

Medical director

PCSO

9

Leadership

Health

Psychiatrist

PCSO

10

Mid-level

Corrections

Shift commander

PCSO

11

Leadership

Legal counsel

General counsel

PCSO

12

Mid-level

Internal affairs and
investigations

Corporal, detention
investigation unit

PCSO

12

Mid-level

Internal affairs and
investigations

Sergeant, detention
investigation unit

30

Vera Institute of Justice

SCDS

13

Leadership

Corrections

Director of
detention services

SCDS

14

Leadership

Health

Health services
administrator

SCDS

14

Leadership

Health

Health contract
administrator

SCDS

14

Leadership

Health

Chief legal officer for
contract healthcare
provider

SCDS

14

Leadership

Health

Chief of operations for
contract healthcare
provider

SCDS

15

Mid-level

Corrections

Sergeant, training

SCDS

15

Mid-level

Internal affairs and
investigations

Sergeant, internal affairs

SCDS

16

Leadership

Health

Mental health manager

SCDS

16

Leadership

Corrections

Lieutenant

SCDS

16

Leadership

Corrections

Lieutenant

SCDS

17

Leadership

Internal affairs and
investigations

Director of risk
management

SCDS

18

Line

Health

Psychiatric nurse
practitioner

SCDS

19

Line

Health

Physician assistant

SCDS

20

Line

Corrections

Officer

SCDS

21

Mid-level

Corrections

Sergeant

SCDS

22

Line

Health

Mental health
professional

SCDS

22

Line

Health

Mental health
professional

SCDS

32

Leadership

Health

Medical director

Preventing Suicide and Self-Harm in Jail: A Sentinel Events Approach

31

Endnotes
1	

2	

3	

Margaret E. Noonan, Mortality in Local Jails, 2000-2014—
Statistical Tables (Washington, DC: Bureau of Justice
Statistics (BJS), 2016), 1, https://perma.cc/E4JX-ULZF.
Ibid.; and Centers for Disease Control and Prevention,
National Center for Injury Prevention and Control, “Webbased Injury Statistics Query and Reporting System
(WISQARS),” database (accessed November 30, 2018),
https://perma.cc/7W7W-JAWW.
Lindsay M. Hayes, National Study of Jail Suicide: 20
Years Later (Washington, DC: U.S. Department of Justice,
National Institute of Corrections, 2010), https://perma.
cc/4Y2W-8SPZ; and Noonan, Mortality in Local Jails, 2016,
6 & table 4. For 1986 data, also see Lindsay M. Hayes and
Joseph R. Rowan, National Study of Jail Suicides—Seven
Years Later (Washington, DC: Jail Suicide Prevention
Information Task Force, National Center on Institutions and
Alternatives, 1988), https://perma.cc/RDD7-9ZHS.

4	Noonan, Mortality in Local Jails, 2016, table 9.
5	

Kenneth L. Applebaum, Judith A. Savageau, Robert
L. Trestman et al., “A National Survey of Self-Injurious
Behavior in American Prisons,” Psychiatric Services 62, no.
3 (2011), 285-290, 287, https://perma.cc/A2K6-MUMA.

6	

Laura Frank and Regina T.P. Aguirre, “Suicide within United
States Jails: A Qualitative Interpretive Meta-Synthesis,”
Journal of Sociology & Social Welfare 40, no. 3 (2013),
31-52; Henry J. Steadman, Fred C. Osher, Pamela Clark
Robbins et al., “Prevalence of Serious Mental Illness among
Jail Inmates,” Psychiatric Services 60, no. 6 (2009), 761-765,
https://perma.cc/VTQ3-CCUG; and Christine Tartaro and
Rick Ruddell, “Trouble in Mayberry: A National Analysis of
Suicides and Attempts in Small Jails,” American Journal of
Criminal Justice 31, no. 1 (2006), 81-101.

7	

Jennifer Bronson and Marcus Berzofsky, Indicators of
Mental Health Problems Reported by Prisoners and Jail
Inmates, 2011-12 (Washington, DC: BJS, 2017), 1 & 8,
https://perma.cc/RF6Y-G426.

8	

See Lindsay M. Hayes, “Suicide Prevention in Correctional
Facilities: Reflections and Next Steps,” International Journal
of Law and Psychiatry 36, no. 3-4 (2013), 188-194. Also see
Noonan, Mortality in Local Jails, 2016.

9	

Hayes, “Suicide Prevention in Correctional Facilities,” 2013.

10	 Leah Pope and Ayesha Delany-Brumsey, Creating a
Culture of Safety: Sentinel Event Reviews for Suicide and
Self-Harm in Correctional Facilities (New York: Vera Institute
of Justice, 2016), https://perma.cc/FF7Q-VT43.

32

Vera Institute of Justice

11	Ibid.
12	 James M. Doyle, “Learning from Error in the Criminal
Justice System: Sentinel Event Reviews,” in Mending
Justice: Sentinel Event Reviews (Washington, DC: U.S.
Department of Justice, National Institute of Justice, 2014),
3-19, https://perma.cc/HE2F-CG52.
13	 Institute of Medicine, Committee on Quality of Health
Care in America, To Err is Human: Building a Safer Health
System, edited by Linda T. Kohn, Janet M. Corrigan, and
Molla S. Donaldson (Washington, DC: National Academy
Press, 2000), https://perma.cc/6RWD-A8LV.
14	 Pope and Delany-Brumsey, Creating a Culture of Safety,
2016.
15	Hayes, National Study of Jail Suicide, 2010.
16	 Each jail received an interim report with preliminary
findings and recommendations specific to its site and
reviewed the penultimate version of this full report.
17	 American Correctional Association (ACA), Core Jail
Standards, 1st edition (East Peoria, IL: Versa Press,
2010), https://perma.cc/MSZ9-URLS; ACA, Commission
on Accreditation for Corrections, Performance-Based
Standards for Correctional Health Care in Adult
Correctional Institutions (Glen Burnie, MD: TrayPML, 2002);
and National Commission on Correctional Health Care,
Standards for Health Services in Jails (Chicago: National
Commission on Correctional Health Care, 2014).
18	 Interviews were audio-recorded and transcribed verbatim
for analysis, with the exception of one participant who did
not wish to be audio-recorded but agreed to have detailed
notes taken.
19	 Kathy Charmaz, Constructing Grounded Theory: A
Practical Guide through Qualitative Analysis, 1st edition
(London: SAGE Publications, 2006); and Dedoose
Version 8.1.8 (Los Angeles: SocioCultural Research
Consultants, LLC, 2018) (web application for managing,
analyzing, and presenting qualitative and mixed method
research data), www.dedoose.com.
20	 Estelle v. Gamble, 429 U.S. 97 (1976),
https://perma.cc/M2FG-ANW5.
21	 SCDS was the only jail in the study not accredited by either
the NCCHC or the ACA.
22	 Katharine Browning, Thomas Feucht, Nancy Ritter et al.,
Paving the Way: Lessons Learned in Sentinel Event Reviews
(Washington, DC: National Institute of Justice, 2015), 1,

https://perma.cc/Q8HK-CFYH.
23	 Pew Charitable Trusts, Jails: Inadvertent Health Care
Providers (Washington, DC: Pew Charitable Trusts, 2018),
10 & figure 2, https://perma.cc/R4Y3-GAYZ.
24	Ibid.
25	Ibid.
26	 There are, of course, other challenges presented when jail
operations and health care services are provided by the
same entity, in particular the challenges that can arise
when health care services lack clinical independence.
Health professionals working in corrections often have
dual loyalty to their patients and to their institutions, and
conflicts related to this dual loyalty can be magnified in
the absence of an independent health service. This was not
the focus of this study, although findings are presented
at page 13 on the sometimes uneasy relationship between
corrections and health staff. See Jörg Pont, Steffan Enggist,
Heino Stöver et al., “Prison Health Care Governance:
Guaranteeing Clinical Independence,” American Journal of
Public Health 108, no. 4 (2018), 472-476.
27	 Hayes, “Suicide Prevention in Correctional Facilities,” 2013.
28	 Doyle, “Learning from Error in the Criminal Justice System,”
2014.
29	 Lorna A. Rhodes, Total Confinement: Madness and Reason
in the Maximum Security Prison (Berkeley, CA: University
of California Press, 2004), 133. For a more thorough
description of the “tentative and shifting alliance” among
custody and treatment workers in prisons, see ibid., 134.
30	 Tobias Jung, Tim Scott, Huw T.O. Davies et al., “Instruments
for Exploring Organizational Culture: A Review of the
Literature,” Public Administration Review 69, no. 6 (2009),
1087-1096; and Mary K. Stohr, Craig Hemmens, Peter A.
Collins et al., “Assessing the Organizational Culture in a
Jail Setting,” Prison Journal 92, no. 3 (2012), 358-387.
31	 Jung, Scott, Davis et al., “Instruments for Exploring
Organizational Culture,” 2009; and Stohr, Hemmens,
Collins et al., “Assessing the Organizational Culture,” 2012.
32	 See for example Gregoire v. City of Oak Harbor, 170
Wash.2d 628, 635, 244 P.3d 924 (2010), https://perma.cc/
Q6L9-47QF; Estate of Cills v. Kaftan, 105 F.Supp.2d 391, 397
(D. N.J. 2000), https://perma.cc/F3A3-UKAS; and Guice v.

Enfinger, 389 So.2d 270 (Fla. Dist. Ct. App. 1980) (holding
that a jail employee must act to prevent “reasonably
foreseeable” suicides and acts of self-harm),
https://perma.cc/6P9E-K3AX. Also see Cook ex rel. Estate
of Tessier v. Sheriff Monroe County, 402 F.3d 1092, 1122 (11th
Cir. 2005).
33	 See 42 U.S.C. § 1983 (providing a civil cause of action
for deprivation of federal constitutional rights); and
Restatement (Third) of Torts: Physical and Emotional Harm
§ 40 (American Law Institute 2012) (affirmative duties to
act), https://perma.cc/6R5L-D72M.
34	 For Florida, see Fla. Stat. § 90.502 (lawyer-client privilege);
and Florida Rules of Civil Procedure, Rule 1.280(b)(4)
(trial preparation materials). For Massachusetts, see
Massachusetts Rules of Evidence, Rule 502 (attorney-client
privilege); and Massachusetts Rules of Civil Procedure,
Rule 26(b)(3) (trial preparation materials). For New Jersey,
see N.J. Stat. Ann. § 2A:84A-20 (lawyer-client privilege); New
Jersey Rules of Evidence, Rule 504 (lawyer-client privilege);
and Rivard v. American Home Products, 917 A.D. 286 (N.J.
Super. Ct. App. Div., 2007) (discussing both attorneyclient and work product privileges). For Washington, see
Washington Rules of Enforcement for Lawyer Conduct,
Rule 5.4(b) (attorney-client privilege); and Washington
Supreme Court Civil Rule 26(b)(3) (trial preparation
materials).
35	 See for example Libertarians for Transparent Government
v. Government Records Council, 180 A.3d 327 (N.J. Super.
App. Div. 2018) (exempting “deliberative material” from
disclosure); Citizens for Open Government v. City of Lodi,
205 Cal. App. 4th 296, 305 (2012) (discussing deliberative
process privilege); Reichhold Chemicals, Inc. v. Textron,
Inc., 157 F.R.D. 522, 524-26 (N.D. Fla 1994) (discussing
self-critical analysis privilege); and O’Connor v. Chrysler
Corp., 86 F.R.D. 211, 217 (D. Mass. 1980) (discussing critical
self-evaluation privilege).
36	 For example, compare discussion of the scope of public
record exemptions in New Jersey and Washington in
Libertarians for Transparent Government, 180 A.3d 327, 331
(N.J. Super. App. Div. 2018); and Residential Action Council
v. Seattle Housing Authority, 177 Wash.2d 417 (2013).
37	 Wash. Rev. Code § 70.41.200.
38	 Mass. Gen. Laws, ch. 111 § 204, https://perma.cc/6JCW2Y6P; and ibid., ch. 111 § 1 (definition of medical peer review
committee), https://perma.cc/6LNQ-UREL.

Preventing Suicide and Self-Harm in Jail: A Sentinel Events Approach

33

39	 McClain v. College Hospital, 99 N.J. 346, 492 A.2d 991
(1985), https://perma.cc/FU8G-GFMK. Also see Muenken
v. Toner, No. L-591-06, 2011 WL 2694431 (N.J. Super. Ct. App.
Div. July 13, 2011).
40	 Edwards v. Thomas, 229 So.3d 277, 286-288 (Fl. 2017),
https://perma.cc/P8WP-KM2W.
41	 Pope and Delany-Brumsey, Creating a Culture of Safety,
2016, 20.
42	See Sanchez v. State of New York, 99 N.Y.2d 247, 252 (2002),
https://perma.cc/MJ65-DZFE; Cook ex rel. Estate of Tessier
v. Sheriff Monroe County, 402 F.3d 1092 (11th Cir. 2005); and
Slaven v. City of Salem, 438 N.E.2d 348, 449 (Mass. 1982).
43	 See for example Md. Code Gen. Prov. § 4-344; Mass. Gen.
Laws, ch. 4 § 7(26)(d); N.J. Open Public Records Act, N.J.
Stat. Ann. § 47:1A-1.1; N.Y. Public Officers Law § 87(2)(g); and
Tex. Govt. Code § 552.111. The scope of these exceptions
may be limited by the common law right of access. See
for example Bergen County Imp. Authority v. North Jersey
Media Group, Inc., 370 N.J.Super. 504 (App. Div. 2004),
https://perma.cc/M3ZD-SVY2.
44	See Estelle v. Gamble, 429 U.S. 97 (1976).
45	 45 C.F.R. § 164.502.
46	 45 CFR Part 160; and 45 CFR Part 164, subparts A & E.
47	 For example, 42 CFR Part 2 is a federal regulation governing
confidentiality for people seeking treatment from substance
use disorders and, with limited exceptions, requires patient
consent for disclosure of patient records. For state health
privacy laws, see for example Cal. Civ. Code § 56.11; Fla.
Stat. §§ 119.0712 & 456.046; Mass. Gen. Laws. ch. 111, § 70E;
N.Y. Social Services Law § 461-d; N.J. Stat. Ann. §§ 26:2B-20
& 30-4:24.3; and Wash. Rev. Code § 70.02.020.

34

Vera Institute of Justice

48	 Melissa M. Goldstein, “Health Information Privacy and Health
Information Technology in the US Correctional Setting,”
American Journal of Public Health 104, no. 5 (2014), 803-809.
49	 45 CFR § 164.512; and 45 CFR § 164.104.
50	 45 CFR § 164.512(b)(1)(i); and National Center for Fatality
Review and Prevention, “HIPAA,” https://perma.cc/PV7LZWRG.
51	 45 C.F.R. 164.502(b).
52	 45 C.F.R. 164.514(a)-(b).
53	Noonan, Mortality in Local Jails, 2016, 12 & table 10.
54	 See for example Vera’s “In Our Backyards” project,
https://perma.cc/624L-Z4XJ.
55	 For resources on suicide prevention in correctional
facilities, see National Center on Institutions and
Alternatives, “Publications,” https://perma.cc/65ZJ-AVA3.
56	 Pope and Delany-Brumsey, Creating a Culture of Safety,
2016; Doyle, “Learning from Error in the Criminal Justice
System,” 2014; Browning, Feucht, Ritter et al., Paving the
Way, 2015; and The Joint Commission, Root Cause Analysis
in Health Care: Tools and Techniques, Fifth Edition (Oak
Brook, IL: The Joint Commission, 2015).

Acknowledgments
The authors are grateful for the collaboration and support of the four jail
systems studied for this project: the Middlesex County Department of
Correction (MCDOC), the Middlesex County Sheriff’s Office (MSO), the
Pinellas County Sheriff’s Office (PCSO), and Spokane County Detention
Services (SCDS). In particular, we appreciate the support of Warden Mark
Cranston and Captain Robert Grover (MCDOC), Special Sheriff Shawn
Jenkins and Kashif Siddiqi (MSO), Sheriff Bob Gualtieri, Colonel Paul Halle,
Major Lora Smith, and Gianluca (John) Martinelli (PCSO); and Director
Mike Sparber, former Director John McGrath, and Kristina Ray (SCDS).
We are thankful for the generous assistance provided by Kimara Davis,
Lane Feler, Matthew Cramer, and Sherwin Salar, associates at Clifford
Chance who donated their time to provide an excellent legal analysis on
issues of liability, discovery, and confidentiality in connection with sentinel
event reviews.
We appreciate the contributions of several former Vera staff who helped
envision this project and carry out data collection and analysis: Vedan
Anthony-North, Karen Tamis, and Ayesha Delany-Brumsey. In addition, we
wish to thank the numerous staff at Vera who assisted on this project: Collin
Blinder, Mawia Khogali, and Isaac Sederbaum for help with data collection
and analysis; Lauren Hobby for her work to help us understand the legal
landscape in four states; Jim Parsons for his oversight and guidance; Léon
Digard for his thoughtful editing of the report; Carl Ferrero for design and
layout; and Cindy Reed and Tim Merrill for editorial support.

About citations
As researchers and readers alike rely more and more on public knowledge
made available through the Internet, “link rot” has become a widely
acknowledged problem with creating useful and sustainable citations. To
address this issue, the Vera Institute of Justice is experimenting with the
use of Perma.cc (https://perma.cc), a service that helps scholars, journals,
and courts create permanent links to the online sources cited in their work.

Preventing Suicide and Self-Harm in Jail: A Sentinel Events Approach

35

Credits
© Vera Institute of Justice 2019. All rights reserved.
An electronic version of this report is posted on Vera’s website at
www.vera.org/preventing-suicide-and-self-harm-in-jail.
Cover image: © 2019 Brian Stauffer c/o the ispot
The Vera Institute of Justice is a justice reform change agent. Vera produces ideas, analysis, and
research that inspire change in the systems people rely upon for safety and justice, and works in
close partnership with government and civic leaders to implement it. Vera is currently pursuing
core priorities of ending the misuse of jails, transforming conditions of confinement, and ensuring
that justice systems more effectively serve America’s increasingly diverse communities. For more
information, visit www.vera.org.
For more information about this report, contact Leah Pope, senior research fellow, at lpope@vera.org.

Suggested citation
Jason Tan de Bibiana, Therese Todd, and Leah Pope. Preventing Suicide and Self-Harm in Jail: A
Sentinel Events Approach. New York: Vera Institute of Justice, 2019.

36

Vera Institute of Justice

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