Officials to launch system-wide review of NYC jail suicides, violent acts of self-harm

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NEW YORK — New York City is using a $400,000 federal grant to review suicides and acts of self-harm in city jails with an approach commonly applied when things go wrong in the medical and aviation industries, officials said Tuesday.

The review — dubbed the "sentinel event" approach — is a way to identify systemic breakdowns by investigating occurrences such as suicides and unravelling the chain of events that preceded them, but not for the purposes of punishment.

"What we hope to have at the end of the day is really not a study that we can dust off and put on a shelf but a way forward of acting," said Elizabeth Glazer, director of the mayor's office of criminal justice. "That's the purpose of it is that things change."

The Associated Press reported in June, based on city and state investigative documents, that procedures designed to prevent vulnerable inmates from harming themselves weren't followed in at least nine of the 11 jail suicides since 2009.

Communication breakdowns between mental health staff and guards, sloppy paperwork, inadequate mental health treatment and improper distribution of medication were frequently cited by investigators as factors in the deaths, according to the documents.

A report conducted for city jail officials in 2003 by a national expert on in-custody suicides, which was obtained by AP via a public records request, outlined specific areas in need of improvement to prevent suicides that included those factors identified by investigators in the 11 suicides since 2009.

But officials said the "sentinel event" approach, used after fatal plane crashes or when patients die on the operating table during surgeries, seeks to get to the root causes of an unexpected, tragic outcome that is often the final result of a series of mistakes. The reviews target systems and processes, not individuals.

"It's basically a way of learning from errors in a system, things that go wrong in a non-blaming way," said Jim Parsons, the project's principal investigator and a researcher with the criminal justice nonprofit Vera Institute of Justice. "It's designed to understand the situation that led to a particular event."

Suicide is the leading cause of death in jails nationally after illnesses such as heart disease and cancer. New York's rate of 17 suicides per 100,000 inmates is well below the average for the nation's jails of 41 per 100,000.

In addition to suicides, city officials said there were 2,514 incidents of self-harm on Rikers Island between 2007 and 2011.

The three-year project, funded by the Department of Justice's National Institute of Justice, will examine the city's current procedures for reviewing jail suicides and serious acts of self-harm; improve the communication between the Department of Correction and the Department of Health and Mental Hygiene, which is responsible for inmates' mental health; and incorporate best-practices from other industries.

Union leader Norman Seabrook said that he supports preventing inmate suicides and acts of self-harm, but he said the grant would be better used providing more programming, better education and other services for vulnerable inmates.

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