Prisons ombudsman reports 64% increase in suicide rates

The number of self-inflicted deaths in prisons increased by a troubling 64% in 2013-14, said Prisons and Probation Ombudsman Nigel Newcomen, as he published his annual report.

He added that, although he could not yet definitively explain this increase, it reflected the level of mental ill health in prison and a rising toll of despair among some prisoners. It also suggested the need for the Prison Service to review its suicide and self-harm procedures.

The Prisons and Probation Ombudsman (PPO) independently investigates the circumstances of each death in custody and identifies lessons that need to be learned to improve safety.

In 2013-14:

• the PPO started 239 investigations into deaths in prison, immigration detention and probation service approved premises, 25% more than the previous year;
• there were 90 apparently self-inflicted deaths, 64% more than the previous year;
• 130 deaths were from natural causes (up 7%), nine were classified as ‘other non-natural’ and a small number (six) await a cause of death; and
• there were four homicides, twice as many as the year before.

Most deaths in custody were from natural causes. Those over 60 are the fastest-growing segment of the prison population and this largely explains the continuing rise in the number of deaths from natural causes, up a further 7% from the previous year.

Nigel Newcomen said: “Prisons designed for young men are having to adjust to the largely unexpected and unplanned new roles of secure care home and even hospice. Commendably, my investigations suggest that some prisons and their healthcare partners are making progress towards better end of life care, but this remains variable”

On suicides, he said: “We cannot yet offer a definitive explanation for the increase, but the case studies and learning lessons material provided in this annual report illustrate that some sadly familiar issues continue to recur. For example, there have been too many instances of prisons failing to adequately identify the risk of suicide posed by prisoners, despite clear warning signs being present. Even where risk of suicide was identified, monitoring arrangements and case reviews were too often inadequate.

“It has been suggested that prison staff are now so stretched, and the degree of need among some prisoners so high, that they may no longer be able to provide adequate care and support for some vulnerable prisoners. The evidence for this remains anecdotal and every day prison staff do save many prisoners from themselves – an achievement which goes largely unreported and without which the tragic number of suicides would be even higher. Nevertheless, the prison system is undeniably facing enormous challenges.

“It is nearly a decade since the Prison Service introduced its current suicide and self-harm procedures and, given the examples of poor implementation described in this annual report and the worrying increase in suicides, I believe it is time to review and refresh these arrangements.”

Internally, the year saw a substantial improvement in the timeliness of PPO death in custody investigations with 92% of draft reports issued on time, compared to 56% the year before. This progress informs bereaved families more quickly about what happened to their loved ones, allows lessons to be identified faster and contributes to efforts to speed up the inquest system.

The other principal part of the PPO’s remit is the independent investigation of complaints. In 2013-14:

• the total number of complaints received dropped slightly to 4,879, which is 495 fewer than 2012-13;
• the proportion of complaints eligible for investigation was 53% compared with 59% in 2012-13;
• 2,111 investigations were started, 25% fewer than in 2012-13, however, 74 more eligible cases were not investigated because there was judged to be no substantial issue or worthwhile outcome;
• 34% of complaints were upheld, a 3% increase on 2012-13; and
• the largest category of complaints was about property, accounting for 26% of the investigat ions completed.

Nigel Newcomen said: “The squeeze on resources and regimes is likely to increase complaints from prisoners about an actual or perceived deterioration in their treatment and conditions. This will not engender much public sympathy, but ensuring an effective mechanism for independent resolution of complaints is a cornerstone of a fair prison system.

“We have been working hard to reduce a large backlog of complaints and, with new ways of working, it is coming down. Importantly, more recent complainants received a better service with most new cases dealt with on time. However, the demands upon us are likely to increase significantly as a result of various Government policy changes, so we will continue to have to operate in a challenging environment.

“We have also had to introduce much greater proportionality, so that scarce resources are targeted on the most serious complaints where there is most to learn and most to put right. While I am very conscious that small things can mean a lot to prisoners with very little, this has been a necessary, but not always popular process of rationalisation.”

The recommendations made as a result of PPO investigations are key to making improvements. The past year also saw the publication of a range of learning lessons bulletins designed to encourage improvement more broadly than is possible with individual investigations. One publication looked at lessons to be drawn from the small number of homicides in prison. Recent reviews of the identification of risk factors in self-inflicted deaths and suicide prevention procedures should help the Prison Service review and refresh its safer custody procedures.

Significant lessons also emerged from thematic reviews of complaint investigations, including how to minimise the use of force and thus better protect both prisoners and staff, and how to avoid the unnecessary cost to the public purse of investigating and compensating prisoners for lost or damaged property.

The annual report can be downloaded here: http://www.ppo.gov.uk/docs/PPO_Annual_Report_2013-14_FINAL_web.pdf