Data limitations

The PPO does not currently hold sentencing data on its case management system, although  investigators usually record basic sentencing details as part of their reporting of a fatal incident. This may be relevant, particularly when making recommendations following an investigation. In the cases of deaths of individuals on remand, recommendations commonly related to issues around reception, initial assessment, and the identification of risk factors and potential triggers for self-harm or suicide (e.g., upcoming court appearances and/or sentencing). 

The article in the Investigator newsletter identifies three main findings from the PPO’s investigation into deaths on remand, including examples of inadequate practice which might have contributed to a person’s death.

Documentation

The PPO has frequently made recommendations reminding reception staff to consider all documentation that arrives with a prisoner to properly assess their risk of suicide and self-harm.  This was not done in the case of Mr A:

Mr A died of self-inflicted causes within a month of being remanded to prison for the first time. When he arrived, his Person Escort Record (PER) was not reviewed, meaning significant information about his risk of suicide and self-harm was missed. A reception nurse also gave too much weight to Mr A’s presentation rather than his range of significant risk factors and staff did not start ACCT measures (the Prison Service suicide and self-harm prevention procedures).

Considering all risk factors

The PPO has also made recommendations in remand cases that all risk factors should be considered and recorded when assessing a prisoner’s level of risk – staff should not just rely on what the prisoner says or how they appear at the time. This issue, termed “professional curiosity” in probation settings has been a feature in recent serious further offence reviews when a person under probation supervision has committed a murder or serious sexual assault.

Mr B, who despite telling the reception nurse he had attempted suicide several times (most recently the same month he was remanded into custody), stated he had no current thoughts of suicide. As a result, the decision was made not to start ACCT measures. Like Mr A, in the case of Mr B, we found that staff did not properly assess his risk of suicide and self-harm based on his known risk factors. We recommended that healthcare staff should not rely solely on the prisoner’s stated intentions.

Flagged triggers for potential self-harm and suicide

In its investigations, the PPO has also highlighted that court dates for trials and sentencing hearings are potential triggers for self-harm and suicide. These triggers should be identified and flagged to relevant staff and following court dates and hearings, prisoners should be re-assessed for their risk of suicide and self-harm.

Mr C was attending court daily for his trial. Following the trial, he was convicted and was due to attend court the next day for sentencing. However, staff who saw him when he returned to the establishment were unaware of his change in status [from being on remand to convicted awaiting sentencing]. The following morning, during a roll check, Mr C was found dead on the floor of his cell. After Mr C’s death, a prisoner told staff that Mr C had said he would take an overdose if found guilty at court. Mr C’s change in status from a remand prisoner to a convicted prisoner should have triggered a reassessment of his risk of suicide and self-harm and a referral to healthcare staff based on this risk assessment.

In addition to the change in status from remanded to awaiting sentencing, court appearances more generally are potential triggers, and the PPO recommends that staff speak to prisoners following court appearances to assess whether their risk has changed and take appropriate action.

Mr D was on remand and attending trial via video link. He was found, two days after his trial began, unresponsive with drug paraphernalia in his cell. There was no record that staff followed local practice and spoke to Mr D about any concerns he might have had following his court appearances in the days leading up to his death.

Conclusion

The tragic case studies above highlight the continuing need for thorough reception procedures, including examining of all documentation that arrives with the prisoner, identifying and assessing risk factors over how an individual may present, record-keeping and making appropriate referrals or application of ACCT procedures. The PPO says it is also important to highlight triggers for self-harm and suicide specific to those on remand, such as court appearances and sentencing. 

Thanks to Andy Aitchison for kind permission to use the header image in this post. You can see Andy’s work here