12 suicides in 2016

It was the sad duty of the Prisons & Probation Ombudsman to publish yet another learning lessons bulletin last week (28 March 2017) on Self-inflicted deaths among female prisoners.

I include the foreword to the bulletin from Nigel Newcomen, the Ombudsman, in full as he describes his position:

This bulletin was prompted by the recent dramatic and depressing rise in self-inflicted deaths of women in prison. It looks at 19 investigations between 2013 and 2016 of instances where women took their own lives. This small sample cannot explain this apparently rising toll of despair, but the bulletin does identify a number of important areas of learning.

This learning focuses on improving suicide and self-harm prevention procedures, better assessment and management of risk, addressing mental health issues, combating bullying and ensuring timely emergency responses.

I have to add I find it disheartening that many of the lessons we identify repeat those in previous publications from my office. This suggests it is not a lack of knowledge that is the issue, but a lack of concerted and sustained action. While we often identify examples of excellent and compassionate care by individual staff, and also recognise that prisons have been under enormous strain in recent years, there can be no excuse for not implementing essential safety arrangements that could ensure vulnerable women in prison are better protected.

It is to be hoped that delivering safer outcomes for women (and men) in prison will be at the heart of the Government’s new prison reform agenda, and that this bulletin can assist with this and help reverse the unacceptable and tragic rise in self-inflicted deaths.

The graph below shows just how desperate the situation is, even more so when you remember that the female prison population has been falling over recent years:

Four key themes

This bulletin draws on a review of recent fatal incident investigations. These were nineteen fatal incident investigations into self-inflicted deaths of female prisoners who died over the period 2013 to 2016 (each completed case of that type from this time period). It seeks to highlight common issues and lessons in order to contribute to improved safety in prisons. The Ombudsman identifies four main themes linked to the preventable suicides of women in prison and illustrates them via a number of case studies. The themes are:

1. Effectively identifying, monitoring and responding to risk is central to preventing prisoners from killing themselves. A previous PPO thematic report set out the need to address risk factors for suicide and self harm. The cases reviewed provide more recent examples where risk was not handled appropriately with the most serious consequences in some instances.
2. The cases also demonstrate the difficulties prisons face in dealing with particular risks, among them mental ill heath and bullying, the latter often being drug-related as the reports highlight. The challenge of meeting the needs of prisoners with mental ill health was explored in more detail in a recent PPO thematic report.
3. The Assessment, Care in Custody and Teamwork (ACCT) process provides the procedural framework for the management of suicide and self harm risk in prison. The cases reviewed provide more examples of failure to implement the process properly or to manage its use effectively, in line with learning previously disseminated in another PPO publication on the self-inflicted deaths of prisoners subject to ACCT monitoring.
4. The cases reviewed also demonstrated the need for an effective emergency response, which may mean the difference between life and death.

Recommendations

The Ombudsman highlights six key recommendations:

1. prisons should ensure vigilance in risk management, proactively identifying suicide and self-harm risk based on established risk factors and triggers particular to the individual, and not just relying on how they present themselves to staff;
2. where risk is identified, prisons should implement the care-planning system to support prisoners at risk of suicide and self-harm (known as ACCT) effectively, and with appropriate management oversight;
3. prison mental health services should ensure that all cases are treated with an appropriate degree of urgency, and avoid delays with assessment and care;
4. prisons should ensure officers are vigilant for signs of intimidation or drug misuse to protect prisoners’ safety. Bullying is often related to drug debts, so where drug activity is suspected, staff should be on the lookout for signs of bullying;
5. prisons should ensure that ambulances are despatched without delay in the event of medical emergency; and
6. prisone should ensure all staff, including night shift staff, carry cut-down tools.

Conclusion

As you can see, the Ombudsman has issued specific guidance on three of these four themes and yet nothing has changed — or more accurately, not enough has changed to prevent more unneeded deaths.

Once again, the Ombudsman’s overall conclusion is that care from individual staff is often very good but weak practice and basic failings remain depressingly common place.

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