World Suicide Prevention Day – The Vera Report into Sentinel Events

Following on from last week’s post, I’ve been curious to understand how preventing suicide in places of detention is applied in another country outside of the UK. I was drawn to the US Correctional System and found this report by The Vera Institute of Justice to be of interest. An insightful read.

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 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.

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 US 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 forward-looking approach to safety. Put into practice in jails, they are one important step toward implementing a comprehensive suicide prevention plan.

Background and Context

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 and therefore making suicide the leading cause of death. Approximately one-quarter of these deaths occur within 24 hours of confinement and half occur within the first two weeks. When I think of American jails, the obvious comparrison for prisons in England and Wales are those local prisons.

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). 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.

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.” 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.

Conducting a Sentinel Event Review

A sentinel event is defined by American healthcare accreditation organization The Joint Commission (TJC) as any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient’s illness. Sentinel events specifically include loss of a limb or gross motor function, and any event for which a recurrence would carry a risk of a serious adverse outcome. Sentinel events are identified under TJC accreditation policies to help aid in root cause analysis and to assist in development of preventative measures.

Sentinel event reviews take a “root-cause analysis” approach, guiding practitioners through the following eight steps:

  1. identify the sentinel event;
  2. gather a multidisciplinary team;
  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
  8. measure the success of corrective actions.

National Standards on Suicide Prevention in Jail

National Commission on Correctional Health Care (NCCHC) standards are the most widely used guidelines for health care delivery in jails. These standards include both clinical and non-clinical 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:

  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.

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:

  • an administrative review assessing the correctional and emergency response;
  • a clinical mortality review answering three questions: (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).

Even with such standards in place, Vera notes that 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.

Key Recommendations: Responses to Suicide and Self-Harm

Develop suicide prevention plans consistent with national standards. Even jails that are not accredited can follow guidance available from the NCCHC or the American Correctional Association (ACA) to develop suicide prevention plans that address the 11 key components of robust suicide prevention programs.

  • Seek out guidance on conducting robust 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.
  • Consistently review incidents of non-lethal self-harm, i.e the “near-misses.” 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 self- harm on a more regular basis.
  • Training on suicide and self-harm prevention should include corrections and health staff together—in person—to foster collaboration and learning across disciplines.
  • Particularly for jails that contract out their 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.

When it comes to collaboration and communication, 2 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.

Key Recommendations: Communication and Collaboration:

  • Corrections and health leadership should work 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.
  • Review processes for suicide and self-harm must 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 information- gathering phase.

Key Recommendations: Organizational Culture

  • Encourage leadership to actively demonstrate its commitment to focusing on system weaknesses and addressing root causes, not individual errors and staff; this will foster trust and candor during review processes.
  • During the review process, build in opportunities for review team members to express their misgivings about the process and work through conflicts.
  • Use trainings on mental health, suicide, and self-harm to develop capacity among staff and overcome the belief that some suicides are not preventable.
  • Highlight positive changes that result from review processes to encourage openness to change.

Key Recommendations: Legal

  • Do not be dissuaded from conducting reviews 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.
  • Work with legal counsel to understand the protections that exist in state law.
  • Champion the value of a sentinel event review process even in the face of liability, not only for improving practices around suicide and self- harm—which is an important goal on its own— but also as way to proactively avoid harm and contain liability.


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 includes addressing regular training of all staff, screening and assessment for suicide risk, communication procedures, housing commensurate with risk level, reporting, and multidisciplinary review processes.

“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.”

10th September marks World Suicide Prevention Day (WSPD) – an awareness day observed, in order to provide worldwide commitment and action to prevent suicides.

The International Association for Suicide Prevention (IASP) collaborates with the World Health Organization (WHO) and the World Federation for Mental Health (WFMH) to host the World Suicide Prevention Day.

Vera – Preventing Suicide and Self-Harm in Jail

Photo by Emiliano Bar on Unsplash