Thursday, 26 February 2015

Prison Suicides: Reducing the Risks

During the recent debate over the rising number of prisoners committing suicide in custody – 84 in England and Wales during 2014 – there has been much discussion of the reasons that some inmates make the decision that life is no longer worth living. However, there has been less focus on whether there are more effective strategies that could be adopted to reduce the number of self-inflicted deaths in custody.

Suicide in prison: rising numbers
I believe that it is an unrealistic expectation that every suicide in prison could have avoided. Moreover, I think that it is essential that members of prison staff are made aware that they can never expect to prevent every suicide in custody. However, the key issues should be risk identification, management, monitoring and mitigation and this is best achieved through the appropriate use of the ACCT system (Assessment, Care in Custody and Teamwork). These procedures are set out in Prison Service Instruction (PSI) 64/2011.

It is important that ACCT procedures should not become a routine ‘box-ticking’ process primarily designed to protect members of staff during the investigations that follow any death in custody. All too often the ACCT document observations log that is supposed to be completed at set intervals for each prisoner who has been identified as being at risk can easily become a routine scribbled note that isn’t particularly meaningful – eg just writing “asleep”. 

I have personally witnessed some appalling lapses of professionalism by bored or demoralised wing screws who have risked making bad situations even worse by belittling or taunting individual prisoners who are on the ACCT book. I have known certain members of staff give the impression that the imposition of these additional monitoring duties are all the fault of those cons who are sometimes seen as being inadequate, soft, needy or babyish.

In short supply
There is also no real substitute for wing officers and managers building up relationships with prisoners in their care and being able to spot changes of behaviour or mood. Although most prisons do operate a personal officer system in which each inmate has a designated uniformed member of staff as a first point of contact, in practice the system often fails to work effectively owing to the sheer pressure of work as staff numbers have been reduced. 

When officers are on leave or off work due to illness, or have been transferred on unattached duty to cover staff shortages at other prisons, there is often a lack of continuity and no handover. As a result, many vulnerable prisoners appear to go unnoticed on the wing, particularly if they aren’t demanding or disruptive. All too often these inmates only come to the notice of staff once they have been found hanging in their cells or lying on the floor in a pool of blood.

Of course, a prisoner who is determined to end his or her life can also plan to avoid becoming the subject of an ACCT document by simply concealing his or her distress or depression. Some inmates – just as with people in the community – can be extremely good at concealing their true intentions when it comes to ending their lives. Someone who has planned their suicide can also take steps to act in between periodic observations and unless a specific inmate is on what is termed ‘constant watch’ for 24 hours a day, then gaps between staff visits, however brief, can provide opportunities for self-harm or suicide attempts.

It is a well-documented phenomenon that some individuals who are severely depressed can seem uncharacteristically cheerful immediate before committing suicide. This is because they feel that have found a way to resolve all their problems. I feel that members of staff, particularly recent recruits, should be made aware of this in order to manage their own expectations that they will be able to identify all prisoners at risk of suicide. They can’t. However, I also believe that higher risk inmates could be managed much better.

Identifying those at risk of suicide
There are several identified risk factors when it comes to suicide in custody. Unconvicted remands are recognised as a group at particular risk of suicide, in some cases due to the uncertainty of their situation pre-trial. Some establishments have extremely poor practices when it comes to managing remanded prisoners. In some cases they are treated exactly like convicted prisoners in respect of wearing prison-issue clothing, being made to work and being accommodated with convicted prisoners.

My own view is that Cat-B locals that accept prisoners straight from court should appoint a remand lead or focal point who is tasked with managing prisoners on remand. Each remand prisoner should have an individualised custody plan (since they cannot by definition have a sentence plan). This should identify personal needs in respect of education or skills, interest in working, healthcare needs, dependencies etc. The emphasis should be on avoiding a period spent on remand as ‘wasted time’. Unfortunately, remand prisoners are often overlooked when it comes to being encouraged to apply for work or education courses. 

I would strongly recommend that unless absolutely unavoidable, all male remand prisoners should be positively encouraged to wear their own clothing and made aware at initial reception of all their specific rights and privileges under the Prison Act and the Prison Rules (female prisoners, whether convicted or remand do not have to wear prison-issue clothing). This may best be achieved by means of a first night interview with an experienced officer who sets out these matters clearly. A printed handout listing remand rights should also be seen as good practice, even though I have never come across this being offered in any establishment I’ve been in.

Listeners play a vital role in prisons
The use of Insiders (or their local equivalents) as peer mentors can be particularly important during early days in custody, both for remands and newly convicted prisoners. Samaritan-trained Listeners also play a vital role in helping inmates in distress by providing an opportunity for them to talk about their fears and problems. I believe that appropriate interventions can significantly reduce the risk of suicide among this particular group.

Many suicides – or serious suicide attempts – are preceded by a complex series of events. These can include receiving a very lengthy sentence (or a life/indeterminate sentence); relationship breakdown; increasing ill-health; mental health problems or the death of a loved one. Suicide can also follow incidents of bullying or assault, including sexual assault while in custody. In many cases such incidents are closely linked to the availability of drugs – both legal and illegal – on prison wings and the culture of debt that can easily arise from drug use. Such bullying and threats of severe violence can easily push a vulnerable inmate over the edge.

I believe that it also needs to be recognised that for many prisoners the future is likely to be extremely bleak, especially those serving indefinite or very lengthy sentences. A significant number who are released on long licences might also be recalled at some point and prisoners on recall, like remands, are recognised as a specific group who can be at elevated risk of self-harm or suicide particularly shortly after they have been recalled to prison.

Recalled to prison and at higher risk
In some cases, a period spent in custody following a recall can be even more stressful than the original custodial element of the sentence, especially when re-release on licence is subject to the Parole Board. The most tragic single case of any prisoner suicide I was involved with was of a young prisoner on recall who simply couldn’t face being returned to custody. He hanged himself in the early hours of the morning a few days after having been taken off the ACCT system.  

I would recommend that all newly recalled prisoners should receive an in-depth review by the mental heath team during the reception process. It should never be assumed that just because a newly recalled prisoner has no documented history of self-harm or suicidal thoughts during a previous period in prison, the change in their circumstances cannot be assumed to have left them unaffected. When it comes to suicide reduction, such assumptions can prove fatal.

My own view is that the use of inmate peer mentors – Listeners, Insiders and Safer Custody reps – needs to be carefully managed by the Safer Custody teams. I have previously argued in blog posts that staff shortages should not place additional responsibilities and inappropriate burdens on other prisoners. Indeed, the agreement with the Samaritans clearly states that establishments should not use Listeners as ‘baby-sitters’ for prisoners considered to be at risk.

Prison can be a lonely place to die
In an ideal world, prisoners should probably not be used in such positions. However, in the present circumstances, it may be unavoidable owing to staff shortages and scarcity of resources. On that basis, I would recommend that each prison should identify individual prisoners who are willing to be trained to support Safer Custody strategies. They could receive training from members of the psychology department, as well as certification in basic first aid and Heart Start (CPR).

One option could be to have identified Safer Custody reps on each wing who are willing to have a shared cell with a vacant bed in it that can be used in times of crisis. These prisoners should not be Listeners, as this could compromise their non-directive role. Such prisoners could also work closely with Safer Custody staff, managers and wing officers to help support individual prisoners who are considered to be at risk of suicide or serious self-harm.

If prisoners are to be used to support staff in these roles, then I believe that it is important that this is seen as a responsible prison job subject to very careful recruitment criteria and rigorous risk assessment. Those selected should be given appropriate training and support, including having regular opportunities to off-load concerns in group meetings and to share their experiences with both members of staff and fellow peer support workers. The impact of a suicide on fellow prisoners and staff is sometimes underestimated and peer mentors may require counselling following the death of a prisoner with whom they had been working.

TV cables: ligature of choice in cells
Another key objective should be to keep all those inmates who are identified as being at particular risk busy during the core working day. Unfortunately, the current levels of overcrowding at many establishments, combined with staff shortages, have significantly reduced the number of opportunities for purposeful activity, with more and more inmates spending 22 or 23 hours each day locked up behind their cell doors.

Other practical measures could include ensuring that prisoners considered at risk of self-harm or suicide are not accommodated in single cells where the opportunities to act on negative thoughts are likely to be much greater. In addition, TV aerial cables – which are often used as ligatures – may need to be removed from cells or an alternative found, such as the introduction of wall-mounted flatscreen TV sets that don’t require cables long enough to use as a noose.  

Although the problem of suicides in prison is becoming more openly discussed in the media, I also believe that there needs to be a much more open discussion within prisons concerning suicide and self-harm. Too many short staffed establishments have a tendency to over-rely on Listeners and on putting up a few posters on wing notice boards, rather than on ensuring that good Safer Custody practices are followed at all times. While we might not be able to prevent every suicide in prison, a more integrated and imaginative approach – along with appropriate numbers of experienced frontline staff – could certainly play a key role in reducing the overall number of suicides. 


  1. One of the things that would really help is that no probation officer should be allowed to recall anyone on licence unless they have actually been charged with another crime. All too often probation officers seem to recall people on petty infractions of licence conditions and sometimes you don't even need to have actually breached any licence condition to get recalled. That would help because then people could feel more secure whilst on licence if they are vulnerable that they will not be recalled unless they are dumb enough to get charged with another crime.

    Secondly ACCT procedures are a good idea in theory but a lousy idea in practice because they are nothing more than a box ticking exercise. It would be far better instead of sticking someone on an ACCT which basically means they are locked in their cell all day and left alone to stew and then woken up every half hour or hour at night thus becoming completely sleep deprived which only adds to their turmoil, for them to be immediately seen by mental health and then seen every day by mental health until they cease feeling suicidal. This can be backed up by Listeners. But often in my experience the prison simply sticks someone on an ACCT, goes through the motions and then wonders why someone kills themselves. They rarely seem to refer people to mental health provision, provide them with no activities to occupy them and distract them. Leaving the supervision of distressed people to unqualified and untrained prison officers is just stupid.

    The courts also need to play their part in this by not putting people on remand unless they are a proven flight risk i.e. they have done a runner before. All too often they simply remand someone who then ends up walking free from court. If the courts have doubts about someone turning up then tag them, monitor them with conditions if need be and then you can go pick them up if they don't show up for the hearing because you will know exactly where they are. save the public purse a large sum of money to boot. The courts can make an order compelling the local mental health trust to treat people if they have mental health issues whilst out on bail and then when it comes to sentencing them put them in a hospital environment until they are stable. But until you force the courts slap happy stick anyone and everyone in jail approach the prison service will continue to fail to protect vulnerable people because they simply aren't set up to deal with them and never will be with the current mindset of HMPS. And Grayling certainly isn't going to cough up the necessary funding to put proper prison procedures in place to deal with vulnerable people even though it would end up saving lives because this is someone who doesn't appear to value human life at all.

    1. Thanks for your thoughtful contribution. On the issue of recall, I must admit that I'm divided. I can see situations where a person who is on licence can start behaving in a way that gives serious cause for concern even if they haven't yet reoffended. Imagine the public outrage if someone who has a history of violence when intoxicated starts drinking heavily after he or she has been released from prison and no steps are taken by Probation to protect the public. Things escalate and someone gets serious injured or even killed. In those sort of circumstances I can see reasons for recall without the need for a new criminal charge. However, I also believe that recall shouldn't normally be the first option unless there is a significant risk to the public.

      I fully agree with your analysis of the flaws in the ACCT system. As I've written in my post above, the key objective should be to keep people on an open ACCT document busy as much of the time as possible. Several cases of suicide by people I've known occurred when they were on the ACCT book and then locked up 23-hours a day as if they were being punished on the Basic regime. None of this helped, other than convince them that life really wasn't worth living.

      Staff shortage are also a major factor. It simply isn't feasible to expect that the ACCT system can work unless there are sufficient frontline staff to make it function as it is intended. I genuinely believe that the widespread failure of the personal officer relationship is primarily down to two factors: low staff morale and not enough staff to keep prison wings safe while operating normal regimes. Add in a handful of truly uncaring, negligent officers and healthcare staff and you have a recipe for tragedy.

      As far as remand is concerned it is truly a national scandal that people can be held unconvicted in prison for months - or longer - and prosecutions are suddenly dropped just before trial. In some cases this suggests that police and the CPS can be far too credulous or lax in carrying out a proper investigation before making the decision to charge in the first place.

      There have been a couple of recent examples in the past month where even though complainants have had a prior history of making false allegations of varying types, their victim is still held on remand in prison until the complaint finally unravels and the charges are dropped. The impact of this on the person who has been wrongly thrown into jail cannot be overestimated.

      Also, the use of custody in prison, or in police cells, as an unacceptable substitute for mental healthcare is truly shocking. Again, I believe that this is basically all about scarcity of healthcare resources in the community with prisons being used as a form of human (and often inhumane) warehousing for people who should be receiving appropriate care and treatment that our prison system simply isn't able to provide. As from Mr Grayling's grotesque personal views, as we all know he considers the rising suicide rate to be no more than "a blip".

  2. Alex,

    When are you going to write something about being out on probation? You said a while ago that you were going to?

    1. Thanks for the reminder! I will write something on release on licence soon.

  3. Prison officers, apart from being massively overworked, are also human and there are some good & some bad but I've never met one that deliberately taunted someone on an ACCT.

    If prisoners learnt to use their cell bells ONLY in genuine emergencies then officers would have more time (and patience) with prisoners that genuinely need more help.

    1. Thanks for your comments. I definitely agree with your observation that there are both good and bad prison officers. I've met some really decent ones - the sort that in other circumstances you'd probably want to have as friends - as well as some individuals who should never be allowed in a position of trust, particularly dealing with vulnerable adults. Sadly, I've actually witnessed a couple of wing officers in Cat-B locals who seemed to delight in goading prisoners on an open ACCT document. To be fair, there were occasions when other staff clearly disliked what their colleagues were doing, but weak senior management failed to get a grip on the situation.

      I take your point about the cell bells - after all, it's not intended for room service - but all too often prisoners who have made the decision to kill themselves won't seek help because they have already reached the point of crisis unnoticed and unseen. I think it requires wing officers who are experienced enough to recognise the signs that a con is genuinely heading towards self-harm and in this era of chronic staff shortages this is the type of monitoring and observation that can't be done without appropriate human resources.

  4. Write something about the Offender Rehabilitation Act 2014.

    1. Thanks for the suggestion. To be honest, I'm not really a legal expert, but I might be able to write something about the issue of 'spent' convictions, how the new Act has changed the rules and the vexed question of trying to get work when you are an ex-con.

  5. From my own personal experience during my time inside I consider front line staff to be absolutely the most important aspect of reducing suicide and self harm.

    I was sent to prison - for the first time - during a sentencing hearing in Court. At noon I was buying my lunch in Boots as a free man, at 5pm my cell door slammed shut. Such a massive change in circumstances wasn't assessed during reception in prison. I was assessed by a prison nurse. "Do you have any health issues?" 'No' "Do you feel OK in yourself" 'Yes'. That was my 2 minute health assessment. About 20 minutes later I was alone in a cell with no TV, no kettle and nothing to read. Thankfully I didn't have any mental health issues nor was I feeling suicidal. If I had the 'system' would not have detected it.

    Procedures and protocols are all well and good but without good frontline staff noticing disturbing behaviour in inmates is very dangerous. Understaffed prisons and overworked staff cannot pick up on these triggers so it's hardly surprising suicides have increased in relation to the massive reduction in staff numbers.

    I shared a cell with an emotionally disturbed young man who spent many weeks on ACCT, At his worst he was being checked on every 10 minutes. He would have 'conversations' with the officer dealing with inmates on ACCT maybe 3 times a day. Some of these conversations - supposed to gauge his emotional state and lift spirits where necessary - were with officers he'd maybe had problems with in the past or fallen out with. Hardly a comforting chat. Just one officer working on the wings would ask me how he was. I was sharing a small concrete box with him for up to 23 hours a day but only that one officer thought to ask me how he was doing. You get to know somebody really well and a sense of their frame of mind in that environment!

    Sadly the current management of our 'justice' system has removed a huge number of highly experienced frontline staff members and are desperately trying to replace them with new recruits. Hopefully last years 84 suicides will be an all time record. I only hope next years figures are much lower. I'm not sure Grayling is doing much to help those figures.

    1. Thanks for sharing your own prison experiences with us. I fully agree that reception and induction are critical times and there is a common tendency for these initial interviews to be more about ticking boxes on a clipboard than really identifying new prisoners at risk of self-harm or suicide. I had very similar experiences to yourself at pretty much every prison I passed through during my sentence.

      In a previous blog post I highlighted how in one Cat-C I'd been placed in a filthy induction wing cell that was absolutely covered in blood and soiled dressings left by a previous inhabitant who had seriously 'cut up'. There was, quite literally, blood on every surface, including a bloody palm print on the wall by the door where he had leaned while bleeding out, as well as a puddle of congealed blood on the floor. It was shocking and I can only imagine the impact that would have had on a vulnerable or distressed prisoner - and that was before Chris Grayling's latest round of budget cuts.

      Your comments also highlight the vital important of communication between wing staff and individual prisoners. Just having a screw ask if an inmate is OK can sometimes lead to a conversation that reveals all sorts of issues, some of which might ring alarm bells about self-harm or suicide. However, if there aren't enough staff to even run a normal regime timetable or unlock cells so people can go to work or attend education, then I just don't see how frontline screws can develop these lines of communication. That is why so many prisons are now relying - often much too heavily - on Listeners, Insiders and other cons to carry out day to day Safer Custody activities.

  6. I have spent 18 and a half months in prison recently and almost all but one month I was on the ACCT book. I spent my first 6 months at a local cat B, then 2 months at another local cat B with 10 and a half months at a cat C. From the day I was arrested I was on suicide watch in the police cells then the prison, I was left alone in the prison induction cell before I was checked on for 6 hours with no one to talk to and no constant watch which I had at the police station. I went straight from the check in to the constant watch cell with the plastic door and an officer watching me permanently 24 hours a day, I stayed in that cell for 30 days. I had numerous officers come and go, some spoke to me, some even gave me papers and chocolate and we talked for hours. Unfortunately the majority ignored me and left me crying on my bed alone, no prisoners wanted to talk to the weirdo in the plastic cell so I was alone for a long time. I had one saviour, an incredibly good listener who would sit with me for a long time, he offered advice as well which most listeners didn’t as they said they were just there to listen not to talk back, when they were on call I went into my cell alone. I lost count of how many times the officers watching me would fall asleep in the night before I did allowing me once chance to try to take my own life, unfortunately at the time he woke up and pressed his alarm, but now I am glad he did wake up. I never told the senior officers about them falling asleep I didn’t want to cause trouble. After leaving the watch cell I was placed in a 2 man cell with another prisoner, we got on as well as we could with me being in a terrible mental state and 2 more attempted suicides but after a month he wanted out, he couldn’t cope with the officers shining a torch through the window every 10 to 15 minutes. I got another pad mate and he was a heavy sleeper so he coped with the constant checks. The officers were meant to have 3 conversations with me a day but they hardly bothered, it would be a simple “ok?".

    When I was sentenced after 6 months on remand I was moved to another local cat B prison and placed in a single cell still on the ACCT document, the checks stopped, I was meant to be on 15 minute obs but I got nothing, I was on a main wing and I should have been on a VP wing but there was no room so I was locked up for 23 hours a day, just coming out to get my meals and my medication. It was the hardest 2 months of my prison sentence and to top it all my partner who was my co defendant was moved out off the same landing to another cat B with no warning, we would see each other at meal times and at association which we got twice a week if they remembered to collect us. I never once had an assessment about my ACCT book with an SO despite me pointing out many times I was on the book. Fortunately my time at this prison soon came to an end and I was moved to an all VP cat C prison.

    Upon arrival it was obvious I was going to be ok there, I met the officer in charge and we talked about my problems for over an hour and it all went in the ACCT book, I was placed in a 2 man cell with a good old prisoner who didn’t mind me being on the book. The staff took time to talk to me and I was often tannoyed down to the office just for a chat and sometimes a cup of tea. My medication was immediately changed and increased and eventually I was starting to feel better, my obs were gradually extended to once an hour and 3 conversations a day to just the conversations. I felt well enough to come off the ACCT book but it didn’t last. I was moved into a cell with someone who I didn’t get on with and we never spoke once in 2 months to each other so I went back on the book, again the staff were great and supportive. The ACCT book saved my life and I some days miss having the orange book with me now, just for the extra support.

    Sorry for the long post. Thank you for writing your blog, I have been reading from the start and always look forward to the updates. Thank you. Paul

    1. Thanks for sharing your own experiences with us, Paul. I think that contributions like yours are so important because they highlight where the current system lets people down - both prisoners and their families.

      What you have written above provides a good insight into the critical importance of human contact for people deep in crisis. Of course, this is just as relevant outside prison as inside.

      Your comments about the lack of interest or real monitoring by some members of staff while you were on the ACCT book are very revealing. As I've mentioned in previous blog posts some prison staff are fantastic and will always do their best to help, listen and advise, while a significant minority are just clocking in for the salary and really can't be arsed to do anything if they can possibly get away with it.

      Sadly, there are a few screws (and healthcare staff) in each prison who obviously detest their job and the people they are supposed to be caring for and delight in bullying or humiliating prisoners. I've seen them in action on numerous occasions and I'm sure you have too.

      I've often reflected that for some people the prison experience can be the most traumatic of their lives, particularly for those who are living with mental health conditions. Often, the uphill struggle to be get the appropriate diagnosis and medication sorted out and, in some cases, prison healthcare teams just can't cope with the current demand at a time when resources are also being cut. Sadly, some tragedies that could have been avoided with proper management and monitoring are still happening in our prisons.

      It is very interesting to read your overall assessment of the ACCT system and its benefits. Having seen it in action myself on numerous occasions, as well as working to support those who are being monitored, I share your view that it can be a life-saver when properly implemented. However, when it is reduced to being a mere box-ticking exercise, then it provides a thin veneer of 'Safer Custody' cover, while actually failing to achieve its principal objectives.

      You also raise the important point about having suitable cell mates to share with. I've come across some real diamonds inside. People who have - quite literally - saved the lives of others at risk of suicide. As you know yourself, sharing with someone who is on the ACCT book can be a very stressful and disturbing experience, particularly the constant cell-checks and putting on of lights throughout the night, so being willing to endure all of that and still care about the welfare of the person you are sharing with takes real compassion.

      Thanks again for sharing your story with us and I wish you all the best for the future. Alex

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