Self-inflicted deaths
This is a guest post from the Prisons and Probation Ombudsman’s unit on their most recent Learning Lessons Bulletin: Fatal Incident Investigations Learning Lessons Bulletin Issue 22: Self-inflicted deaths in reception prisons – Prisons and Probation Ombudsman.
The number of self-inflicted deaths in reception prisons must come down
The Prisons and Probation Ombudsman is an independent body that investigates complaints from prisoners, people on probation and those held in immigration detention. We also investigate every death in custody, including those that occur post-release. In our death investigations, we aim to understand what happened leading up to the death and identify learning for the organisations involved. The unique nature of our investigations means that we are able to gather insights and key learning into what might be contributing to certain outcomes for prisoners.
Our latest learning lessons bulletin highlights the risks that being in a reception prison brings. Reception prisons have one of the highest rates of self-inflicted deaths of all prison functions, so we tasked ourselves with looking into this further to identify what might be contributing to this concerning fact.
Our team assessed 170 self-inflicted deaths of prisoners in reception prisons over a 5-year period. For those that don’t know, reception prisons are an entry point for people into prison. Prisoners entering reception prisons are mostly on remand or unsentenced, and for some, it can be their first time entering a prison. This particular group of prisoners face uncertainty about their future and are therefore more vulnerable.
The importance of early days in reception prisons
In 11% of cases assessed, self-inflicted deaths occurred within the first 48 hours of entering a reception prison. 30% occurred within the next three weeks, meaning that a staggering 41% occurred within the first month.
Staff working in reception have very limited time to build rapport and conduct early days assessments when each prisoner enters. The high levels of churn in reception prisons and current population pressures contributes to this. It is crucial that staff in reception can quickly and meaningfully identify and support those who pose a high risk of suicide and self-harm. 66% of our sample were not on an ACCT at the time of their death, and concerningly, 21% did not have an ACCT started when the prisoner first entered the reception prison, when it should have been.
In the investigations we reviewed, we often found that collaboration between healthcare and prison staff could have been improved to identify and manage risk in prisoners. Our analysis revealed examples of staff basing their decisions primarily on how a prisoner was presenting themselves rather than an objective assessment of their known risk factors, which is a longstanding issue the PPO continues to find in investigations.
A lack of communication and engagement with this vulnerable group of prisoners can also contribute to their risk of suicide and self-harm. In 7% of cases, we found issues with the prisoner’s phone account, preventing them from having access to their support network which is vital during those early days in custody.
It is clear from these stark numbers that individuals arriving at reception prisons require a particularly careful assessment during their early days in custody. The importance of reception staff cannot be overemphasised. They need appropriate and ongoing support from staff to manage this risk and to bring these numbers down.
Challenges beyond early days
A proportion of prisoners remain in reception prisons for several months, sometimes even years. Reception prisons are not designed to hold people for extended periods of time. Their primary function is to process new arrivals and facilitate movements to longer-stay establishments. When individuals remain in reception prison environments for months, they start to experience the instability, high churn and limited regime that reception prisons present.
Early days in reception prisons clearly present the highest period of risk. However, our research also found that 36% took their life beyond spending three months in a reception prison. It is therefore imperative that effective ACCT management is in place for each prisoner that requires it, both during their early days in custody and beyond. Without this coordinated process, warning signs could be missed and tragedies are more likely.
ACCT checks often not taking place
Within the analysed cases of prisoners who had been on ACCT during their most recent time in prison, 40% of our cases revealed that checks were not carried out by staff as frequently as required. We also found that staff had falsified records in several cases, which we continue to find far too often. ACCT contributes to an at-risk prisoners’ overall stability and rehabilitation – staff should not be falsifying records and there needs to be stronger governance of ACCT in general – both in reception prisons and across the wider estate.
41% of the deaths assessed in our sample occurred near a court hearing. Court hearings and video links are a common occurrence for prisoners in reception prisons and the Prison Safety Policy Framework states that prisoners must be risk assessed regardless of whether their court appearance was in person or by video link. In 32% of cases, this did not happen. Outcomes for prisoners can change after hearings so it is imperative that staff reassess their risk after this takes place.
The importance of key workers
In the bulletin, we also talk about the importance of key worker schemes for prisoners in reception prisons. Key worker schemes are an important part of HM Prison and Probation Services’ response to self-inflicted deaths and are intended to improve safety by engaging prisoners. They present important opportunities to identify changes to a prisoner’s risk and support their mental health. However, many prisoners in our sample had very few or no key work sessions.
An introduction to key work should take place during a prisoner’s induction and formal sessions should take place within their first month at the prison. Key work sessions are especially important for prisoners who are staying in reception prisoners longer than usual to maintain their sense of purpose.
Conclusion
The statistics in our bulletin highlight the grim reality that there are far too many prisoners taking their own life. Support for prisoners in reception prisons needs to be prioritised. Senior leaders across the prison service must ensure that their staff understand that early days in reception prisons are critical – many prisoners are arriving with multiple risk factors and staff must be trained and prepared on how to identify and manage these.
Thanks to Andy Aitchison for kind permission to use the header image in this post. You can see Andy’s work here
