Ms K had a history of mental illness. After a long period of stability, she made several attempts to kill herself and was admitted to a psychiatric hospital. She was discharged to the care of the community team but was arrested almost immediately, when she threatened to kill her former partner.

A doctor decided she would not benefit from further hospital treatment, and she was remanded to prison. It was her first time.

A nurse began the procedures intended to support prisoners at risk of suicide or self-harm. (The assessment and monitoring prcedures are known as ACCT — Assessment, Care in Custody and Teamwork). The nurse recommended that Ms K be kept under constant watch. Instead, prison staff set the rate of observations at four per hour.

Twice that first evening Ms K tried to hang herself. She was moved to a safer cell and kept under constant supervision.

Over the following days, there were several meetings. Clinical staff gave advice that wasn’t followed. Ms K remained in the prison.

Nearly two weeks after her arrival, Ms K was referred to a psychiatrist who ordered a transfer back to hospital. Before that could happen Ms K managed to kill herself.

She was one of 89 people in prisons in England and Wales who took their own lives in the twelve months to March 2014.

Eighty-nine self-inflicted deaths. That’s an extraordinary 64 per cent increase on the previous year’s suicides and higher than fifteen years ago, when rising numbers prompted positive action.

Learning lessons

Nigel Newcomen is the Prisons and Probation Ombudsman, whose job is to investigate and report on every single death in custody. The idea is that families may find out what happened, and the prison service learns lessons and takes action that helps to prevent future deaths.

But time and again the Ombudsman’s Fatal Incident Reports reveal failings that he has previously identified. There are recurring failures to acknowledge the impact of bullying on vulnerable prisoners, for example. Prison staff repeatedly place too much emphasis on how a prisoner seemed, rather than known risk factors, such as recent attempts at self-harm.

And so, in April 2014, Newcomen published two new reports: The first, Learning from PPO investigations: risk factors in self-inflicted deaths in prison, returned to six years’ investigations into 361 such deaths and examined the characteristics of those who had died, the events in the 72 hours leading to their deaths, and the prisons’ approaches to assessing and managing risk. (PDF here)

The second report re-examined 60 investigations concerning prisoners who were being monitored under the suicide prevention procedures when they killed themselves. This one was called Learning from PPO investigations: Self-inflicted deaths of prisoners on ACCT (PDF here).

Prison staircase (National Offender Management Service)Launching his two reports, Newcomen said: “Nearly a decade after the introduction of ACCT (and a range of other safer custody measures) which saw self-inflicted deaths in custody fall, such deaths have risen sharply in recent months. It is too early to be sure why this rise is occurring, but the personal crisis and utter despair of those involved is readily apparent, as is the state’s evident inability to deliver its duty of care to some of the most vulnerable in custody.”

He said: “Learning the lessons from these two reports ought to help the Prison Service improve the implementation of ACCT and ensure greater safety in custody.” He called on the Prison Service to “review and refresh its safer custody strategy in general and ACCT in particular.” He said this was necessary, “given the repeated weaknesses in practice we identify and the rising toll of self-inflicted deaths.”

Breaking point

About Newcomen's “too early to be sure why this rise is occurring” . . . . Last Summer Her Majesty's Prisons Inspectors visited HMP Hewell in Worcestershire where there had been six self-inflicted deaths in two years. Chief inspector Nick Hardwick reported: “Staff did not have enough time to interact meaningfully with prisoners in crisis.” [PDF here] 

Last year a research paper from The Howard League for Penal Reform (Breaking point: Understaffing and overcrowding in prisons) recorded the shocking scale of staff cuts. The number of frontline prison officers in English and Welsh prisons had fallen by 30 per cent since the coalition government came to power in May 2010. Twenty prisons had been closed or partially closed. Yet the prison population had increased slightly from 85,015 to 85,469. (In 1994 the average prison population was 48,621).

What of the urgent action that Newcomen called for almost a year ago to remedy “the state’s evident inability to deliver its duty of care”? 

Didn’t happen.

Instead, the government’s National Offender Management Service, which is accountable for how prisons are run in England and Wales, informed the Ombudsman that action could wait until after the findings of yet another review had been published — Labour Peer Lord Harris’s inquiry into self-inflicted deaths by 18 to 24 year olds, commissioned by justice minister Chris Grayling.

Meanwhile the government pushed its punitive model of justice. “Prison is not meant to be comfortable. It’s not meant to be somewhere anyone would ever want to go back to” Grayling asserted in the Guardian, describing the “recent rise in self-inflicted deaths” as “very unwelcome and unhappy”.

Short of throwing a brick at the minister, what more could an Ombudsman do?

Last Autumn Newcomen held a series of seminars for Prison Service and government staff (you can download his powerpoint presentations here), and carried on analysing, this time comparing the suicides that happened in the year to March 2014 with those that had occurred in the previous year.

A report on that analysis is published today. (Ms K’s story is in it.) This latest report inspires a chilling sense of déjà vu. Newcomen said it was “troubling that many investigations simply repeated criticisms that we have made before. In particular, too many cases illustrated the inadequacy of reception and first night risk assessment. Even when risk of suicide or self-harm was identified, too often the support and monitoring put in place was poor.”

Yet again, he said: “This repeated failure is why I have called for – and continue to call for – a review of Prison Service suicide and self-harm procedures and their implementation.”

Yet again he hoped that the “lessons from this report offer a guide for action and better support for prisoners in crisis.”

Neglect and corporate manslaughter

One man who knows what action looks like is David Ramsbotham, Lord Ramsbotham, the former British Army Adjutant General who served as Her Majesty’s Chief Inspector of Prisons from 1995 to 2001. Yesterday I asked him for a swift response to the latest PPO report. Here’s what he emailed back:

“In 1999, as Chief Inspector of Prisons, I published a report on the prevention of suicide entitled ‘Suicide is Everyone’s Concern’.  In it I called on the then Home Secretary, Jack Straw, to issue a ringing declaration that suicide prevention was a management issue, in which everyone, from him down to every officer on every landing, shared accountability and responsibility.

“This followed an inspection of Brixton during which we found that staff had taped the alarm system in a wing office, so that cell alarm bells would not ring, and that someone had, at 2.15 pm, signed the official register, claiming to have visited the prisoner every 15 minutes until 4pm. I asked the Director-General of the Prison Service to come to the prison at once, to see these for himself, as examples of what could happen if management was not doing its job.”

David Ramsbotham, House of Lords, March 2014

Ramsbotham went on: “Currently staff shortages are causing considerable problems in prisons, because there simply are not enough prison officers to carry out all the tasks with prisoners that are required.

“The first test of whether a prison is doing its job properly is whether everyone in the prison — staff, prisoners, those who work there, or visitors — is or feels safe. Safety should be the absolute determinant of staff cuts, and it would be utterly irresponsible of any Secretary of State for Justice to sanction anything that put safety at risk.” 

He said: “I do not know why Mr Grayling recently announced the recruitment of 1700 prison officers, having just cut more than 4000, but must presume that the cut proved too severe. Nor do I know whether safety was the determinant for his reversal, but, hanging over the Prison Service is the possibility of its management, or members of it, being charged with Corporate Manslaughter, if it can be proved that poor management contributed to a suicide.

“The Corporate Manslaughter Act has never yet been invoked over a prison suicide, but it could be. If it were, and the Secretary of State or other senior managers indicted – for failing to oversee their subordinates, it might prove to be the wake up call that the prison system has needed for years. Of course not every suicide can be prevented, but there have been far too many occasions when failure to observe regulations, let alone oversee a vulnerable prisoner, have resulted in a Coroner castigating prison authorities for neglect, for which management is ultimately to blame.”

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Notes:

 A copy of today’s report, Learning from PPO Investigations, Self-inflicted deaths of prisoners 2013/2014, can be found here.

Chris Grayling’s speech on Conservative justice policy and the recruitment of 1700 more prison officers, at the Prison Reform Trust, 26 January, 2015, is here.

The PPO’s Annual Report 2013/14 is here.