Suicide and self-harm prevention in prison

1. Suicide and self-harm prevention in prison Nigel Newcomen Prisons and Probation Ombudsman Bradley Group meeting 20 June 2017

2. Agenda • The PPO • A system still in crisis? • Still a rising toll of despair • What is ACCT? • Is ACCT still fit for purpose? • Conclusion

3. About the PPO • Roles • Independent investigation of complaints from prisoners, immigration detainees, child detainees and those under probation supervision • Independent investigation of deaths in prisons, IRCs, STCs, SCHs and probation approved premises • Newer emphasis on thematic learning, library of 40 publications since 2012 • Vision: carry out independent investigations to make custody and community supervision safer and fairer

4. System still in crisis • We started investigations into 361 deaths 2016-17 (up 19%) • 115 self inflicted (up 11%) • 208 natural causes (up 19%) • 4 homicides (down from 6) and 34 “other” • Of all deaths, 88% were adult males • Female deaths more than doubled (23) • 11 deaths in APs, 3 in IRCs, 2 in SCHs • 5,026 complaints (up 5%), of which 2,569 eligible (up 10%) • Unprecedented levels of violence • Many of the same issues recurring and lessons either not being learned or learning not being sustained

5. Still a rising toll of despair • Continuing, tragic 11% rise in self-inflicted deaths may beless than the 34% rise 2015-16 but no grounds for complacency • Hard to be definitive about cause of continuing rise: • Staffing cuts, crowding and regime restrictions must all play a part in reducing protective factors against self-inflicted deaths • So must troubling levels of mental ill health • And an epidemic of new psychoactive substances • But each case is an individual crisis, an individual story and no simple, single explanation suffices

6. “Learning from PPO investigations: prisoner mental health” Published January 2016 A thematic review of the identification of mental health needs and the provision of mental health care for prisoners, based on the learning from our fatal incident investigations. Available online: http://www.ppo.gov.uk/?p=6737 • 15/11/2016 • European Custody and Detention Summit

7. “Learning lessons bulletin: new psychoactive substances” Published July 2015 Examines the death of prisoners suspected to have been using NPS Considers risks and behaviour related to NPS use Available online: http://www.ppo.gov.uk/?p=6137 • 15/11/2016 • European Custody and Detention Summit

8. Still a rising toll of self-inflicted deaths • In a complex context, without simple answers, effective efforts by staff are key to preventing self-inflicted deaths. • PPO investigations show much commendable work by staff • But, in a strained prison system, suicide and self-harm procedures (ACCT) not being consistently applied. • As a result, investigations often repeat the same lessons. • This is not good enough and I frequently have to call on prison staff to redouble their efforts. • On the basis of these repeat failures - and what staff tell us - I also continue to question whether effective ACCT still deliverable within current resources

9. What is ACCT? • Introduced in 2005, Assessment Care in Custody and Teamwork (ACCT) is the HMPPS care-planning system used to support prisoners at risk of suicide or self-harm. • Its purpose is to try to determine the level of risk, how to reduce the risk and how best to monitor and supervise the prisoner.  • Process: • initial assessment of prisoner’s main concerns • set levels of supervision and interactions according to perceived risk of harm • checks should be irregular to prevent the prisoner anticipating when they will occur.

10. What is ACCT? • There should be regular multi-disciplinary review meetings involving the prisoner.  • A caremap (plan of care, support and intervention) should be put in place and the ACCT not closed until all actions completed. • All decisions and any relevant observations should be written in the ACCT booklet, which should accompany the prisoner as they move around the prison. • Guidance on ACCT procedures is set out in Prison Service Instruction (PSI) 64/2011.

11. Is ACCT fit for purpose? • In concept, as good as any suicide and self-harm prevention system in any other jurisdiction taking a holistic “whole prison approach” not a limited medical model • Need to be honest and acknowledge that no set of processes will prevent all self-inflicted deaths • Alos mustn’t underestimate role of a safe environment, activity, good staff\prisoner interactions and supportive healthcare • But repeat failures in ACCT reported in investigations suggest disconnect between policy and practice • My (last) annual report (July 2017) will again call on HMPPS to assure itself that staff can effectively implement ACCT.

12. Is ACCT fit for purpose? Issues • Can’t escape resource question: ACCT devised at a time when fewer prisoners and more staff • Dependent on ordinary staff – hence Harris review called for creation of specialist Custody and Rehabilitation Officers • Requires resources staff often complain do not exist • Reception and first night key times to identify risk but also among the busiest processes in local prison • Huge amount of risk and need to manage • Training essential but often deficient • Struggle to achieve continuity of care and case management • Entirely paper based

13. Is ACCT fit for purpose? • Last time I raised similar concerns (2013) there was a cursory review, followed by record numbers of suicides and more repeated PPO recommendations • Now some hope with prison reform agenda, which is reinvesting in prisons and prioritising safer custody • New operational assurance programme underway which may help answer concerns over ACCT • Key workers may increase consistent interactions • Devolution may encourage innovation • But a long, long way to go

14. Conclusion • Prisons in England and Wales facing huge challenges, not least continued and unacceptable increase in self-inflicted deaths • No simple answers • But unacceptable that some deaths reflect repeated failings • These repeated failures – and staff concerns - raise questions over fitness for purpose of ACCT, or at least its deliverability • Much hinges on prison reform but progress will be limited without greater safety and fairness • Prisons need to get better at learning lessons • PPO investigations and thematic learning will continue to support the search for improvement and greater safety