Learning lessons from fatal incident investigations
Eight prisoners killed themselves in prison segregation units in the financial year 2013/14 – four of these had been assessed to be at risk of suicide and self-harm.
Nigel Newcomen, the Prisons and Probation Ombudsman, issued a Learning lessons bulletin focused on fatal incident investigations in June 2015.
The bulletin starts with a clear statement about the purpose of segregation:
[alert-note]”Segregation is an extreme and isolating form of custody used for prisoners who have misbehaved or who cannot be kept safely in normal prison accommodation. It inherently reduces protective factors against suicide and self-harm, such as activity and interaction with others, and should only be used in exceptional circumstances for those known to be at risk of taking their own life.”[/alert-note]
Eight individual tragedies
The bulletin contains four case studies relating to individual prisoners who took their own lives whilst in segregation. These make for profoundly depressing and distressing reading. I reproduce below the full text of Case Study 3:
“Mr C claimed to be at threat from other prisoners and asked to be moved from the wing to the segregation unit. He moved to the segregation unit that day. The next day, a Segregation Review Board authorised his continued stay in segregation. Another review took place the following week, where it was decided that there was no threat to him from other prisoners and that he should be moved back to a normal wing. Mr C refused to move from the segregation unit and subsequently remained there for over three months.
During his time in segregation, Mr C’s mental health deteriorated. On several occasions staff found him to be tearful and he told them he was struggling to cope. In spite of this, a number of subsequent Segregation Review Boards continued to authorise his segregation. Staff recognised that Mr C’s mental health was deteriorating, but there is little evidence to suggest that a structured plan was put together to better support his mental health and combat the detrimental effects of his segregation.
Mr C continued to refuse to move back to a standard wing, believing himself to be at risk there. An attempt was made to move him to another establishment but this was unsuccessful. A decision was then made to move him to the Healthcare Unit for a period of reprieve from segregation. Due to his perceived threat to other prisoners however, he was locked in his cell in the healthcare unit, which effectively resulted in a continuation of segregation conditions.
Mr C stayed in the healthcare unit for over two weeks, before hanging himself in his cell. During this time, he told staff a number of times that he was feeling low, was hearing voices, and had thoughts of suicide.”
Six clear recommendations
The Ombudsman highlighted six key lessons to try to prevent further tragedies; again these are reproduced in full below:
- Staff responsible for the care of prisoners in segregation units should fully understand and follow the mandatory procedures for safeguarding segregated prisoners set out in PSO 1700, Segregation, and PSI 64/2011, Safer Custody;
- Special accommodation and protective clothing should only be used if absolutely necessary and plans should be made to return the prisoner to standard accommodation and normal clothing as soon as possible;
- Segregated prisoners should be provided with the means to occupy themselves, at minimum reading material and a radio;
- During an initial health screen and ensuing reviews, staff should base decisions about fitness for segregation on the prisoner’s full mental health history and other relevant factors that could potentially compromise their ability to cope;
- Lengthy periods of segregation are to be avoided and, when unavoidable, should be regularly reviewed so that a care plan can be developed to help prevent deterioration in mental health; and
- Exceptional circumstances to justify the segregation of a prisoner subject to suicide and self-harm prevention procedures (ACCT) should actually be exceptional.
The number of prison suicides and incidents of self-harm has risen sharply recently.
Despite the best intentions of the Ombudsman, I fear it is reasonable to expect the figures to get worse and for more human lives to be needlessly lost as the Ministry of Justice embarks on another round of cuts.