Friday, April 3, 2015

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Prison Suicides: Reducing the Risks

Alex Cavendish discusses the serious issue of suicide in prison. Alex Cavendish is an author and academic: a social anthropologist, former prisoner and an active participant in the debate surrounding crime, prisons and probation. He blogs at Prison UK: An Insider's View.

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.