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City Launches Initiative To Address Suicides, Self-Harm Incidents In New York City Jails

October 28, 2014

Between 2007 and 2011, there were eight suicides and 2,514 incidents of self-harm at Rikers Island, New York City’s largest jail

NEW YORK—The de Blasio administration today announced plans to implement crucial system improvements to lower the rates of suicide and self-harm among inmates in New York City jails. Funded by a $400,000 grant from the National Institute of Justice, New York City’s Department of Correction, the Department of Health and Mental Hygiene, and the Vera Institute of Justice will embark on a three-year project to standardize review of instances of inmate suicide or self-harm and document what can be done to reduce the likelihood of such instances happening again. 

“This breakthrough initiative makes science an integral part of how we diagnose and fix any systemic failures,” said Elizabeth Glazer, director of the Mayor’s Office of Criminal Justice. “In doing so, this partnership will allow us to better safeguard those in our custody.”

“Far too often inside correctional institutions, violent sentinel events occur that could have been avoided,” said Department of Correction Commissioner Joseph Ponte. “This three-year partnership with Vera and the health department’s Bureau of Correctional Health Services offers the ability to study the causes of these tragic incidents, so that we can reduce their prevalence and improve the safety of all those within our jails.”

Incidents of suicide, suicide attempts, and other acts of self-harm that can result in serious injury are called “sentinel events.” The health department currently has a systematic approach in place to review every case of suicide, which has kept rates of suicide in the City’s jail system well below the national average, despite increasing acts of self-harm.

“The health department is responsible for providing medical and mental health services for the patients inside the City’s jails, and we always are looking to enhance the work we do,” said Dr. Mary Bassett, Department of Health and Mental Hygiene Commissioner. “Suicide is a tragedy, and we know it also is preventable. We look forward to working together to identify high-risk settings, so we can help reduce self-harm and suicide.”

With guidance from national experts in corrections and correctional health care, the project will:

  • Analyze components of the city’s existing procedures for reviewing suicides in the jail and extend them to instances of serious self-harm;
  • Design a process that improves collaboration between Department of Correction and Department of Health and Mental Hygiene staff in conducting reviews and addressing systemic problems;
  • Incorporate best practices from community medicine to develop a more comprehensive, process that can be replicated nationwide for reviewing incidents of fatal and non-fatal self-harm in correctional settings and developing corrective action plans.

“Suicide, self-harm, and prison violence are intersecting problems that endanger and traumatize inmates and staff and perpetuate cycles of harm in correctional facilities,” said Vera Research Director Jim Parsons. “This study will create a process to address an issue that carries enormous human and social costs, and help to bridge the gap between corrections and health systems.”

The three-year program borrows from the methodology effectively employed in other contexts. For example, hospitals routinely conduct sentinel event reviews for incidents such as surgical errors or inpatient suicides, so personnel can examine the circumstances leading up to the event, learn where systems broke down, identify underlying causes, and develop safeguards to prevent these incidents from recurring. In health care settings, these safeguards include instituting checklists to reduce errors, investing in state-of-the-art equipment, and IT solutions that facilitate better tracking of patients and their medical needs. Similar reviews are used in high-risk industries such as aviation, nuclear energy, and military operations.

Vera successfully competed under NIJ’s “Research on ‘Sentinel Events’ and Criminal Justice System Errors” solicitation to receive the grant. For more information about NIJ, visit

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