World Suicide Prevention Day – Learning from PPO Investigations

In this third and final post before this years World Suicide Prevention Day tomorrow (10th September 2019), I wanted to take renewed look the correlation between mental health and prison deaths in custody. One of the most obvious and relevant sources is the PPO Thematic Review of Mental Health published in 2016.

The report considers the deaths of 557 prisoners who died in prison custody between 2012 and 2014, of which 199 were self-inflicted and 358 were from natural causes.

A national survey conducted in 2005 and 2006, which looked specifically at newly sentenced adult prisoners in England and Wales who had been sentenced to four years or less, found that:

  • 61% of the sample were identified as likely to have a personality disorder, 10% a psychotic disorder, and over a third reported significant symptoms of anxiety or depression.
  • 21% of the sample reported feeling that they needed help or support with their mental health.

”Given the scale of mental ill-health in prison and the pressures in the system, it is perhaps not surprising that this review identifies significant room for improvement in the provision of mental health care.” – Nigel Newcomen, CBE. Prisons and Probabtion Ombudsman


The 25 themes listed within the report, are broken down into 2 aspects – (i) the identification of mental health issues and, (ii) the provision of care.

The identification of mental health issues describes lessons learned around:

  • Reception
  • Prison transfers, information sharing, and continuity of care
  • Referrals
  • Assessments
  • Mental Health Awareness

The provision of care describes lessons learned around:

  • Treatment
  • Medication
  • Information Sharing (with prison staff)
  • Co-ordinated Care
  • ACCT
  • Transfer to Secure Hospital
  • Dual Diagnosis
  • Personality Disorder

Identification of Mental Health Issues


Lesson 1: Reception staff should review all the documentation that a prisoner arrives with, and ensure that all relevant information is then passed onto the health professional responsible for the reception health screen.

Lesson 2: The health professional responsible for the reception health screen should ensure that all of the information they receive about a prisoner is given due consideration when making an assessment, including any existing SystmOne records.

Prison transfers, sharing information, and continuity of care

Lesson 3: All staff who use SystmOne should be fully trained in its use.

Lesson 4: NHS England should ensure that community GPs provide comprehensive details of a prisoner’s health records when asked by a prison healthcare team for this information. This should include details of the prisoner’s history of both physical and mental health problems.

Lesson 5: When a prisoner with known complex mental health problems is transferred between prisons, the mental health team in the sending prison should ensure that they provide a comprehensive handover to the receiving prison’s mental health team.

Lesson 6: When a prisoner with known complex mental health problems is transferred between prisons, the mental health team in the receiving prison should ensure that they request and obtain a comprehensive handover from the sending prison’s mental health team.

Making referrals

Lesson 7: Staff have a responsibility to make a mental health referral any time that they have concerns about a prisoner’s mental health.

Lesson 8: Mental health assessments should be carried out promptly after a referral is received, to ensure that necessary care and treatment can be put in place as soon as possible.

Lesson 9: Prisons should ensure that they have a clear and consistent process for prison staff to refer prisoners directly to the mental health team, and that prison and healthcare staff have a shared understanding of this process and how to make urgent referrals when necessary.


Lesson 10: Mental health assessments should take into account all relevant information, use standard mental health assessment tools, and be compliant with NICE guidelines.

Lesson 11: NHS England should produce guidance for prison healthcare to advise them on best practice for the selection and use of existing validated assessment tools.

Mental Health Awareness

Lesson 12: Mental health awareness training should be mandatory for all prison officers and prison healthcare staff, to provide them with necessary guidance for the identification of signs of mental illness and vulnerability.

”All prison staff, not just those in healthcare, need to be able to recognise the major symptoms of mental ill-health and know where to refer those requiring help. Staff training is, therefore, crucial but, too often, my investigations have found that staff lacked the necessary mental health awareness training, and, as a result, the mental health needs of prisoners were missed.” – Nigel Newcomen, CBE. Prisons and Probabtion Ombudsman

Provision of Care


Lesson 13: At a minimum, all prisoners should have access to the same range of psychological and talking therapies that would be available to them in the community. These services should be adapted for use in a prison environment where appropriate.


Lesson 14: Prison and healthcare staff have a responsibility to talk to prisoners and young people who fail to collect or take their medication, to try to ascertain why they have chosen not to comply, and to encourage them to begin taking it again.

Lesson 15: Prison healthcare leads should ensure that a robust system is in place for flagging non-compliance with medication, and that there is clear guidance for healthcare staff about the management of medication and dealing with non-compliance.

Lesson 16: Compliance with all medication should be monitored and encouraged as part of an up-to-date care plan for prisoners with mental health problems.

Sharing Information with Prison Staff

Lesson 17: All healthcare professionals have a responsibility to share with prison staff any information that might affect a prisoner’s safety, within the boundaries of medical confidentiality.

Coordinated Care

Lesson 18: All healthcare teams involved in the care of a prisoner should communicate with each other and share information, to ensure consistency in diagnosis and a collaborative approach to treatment.

Assessment, Care in Custody and Teamwork (ACCT)

Lesson 19: The mental health team should attend or contribute to all ACCT reviews for prisoners under their care, and should be fully involved in any important decisions about location, observations, and risk.

Transfer to Secure Hospital

Lesson 20: Prisons need to be extra vigilant about the care of prisoners who are being considered for, or are awaiting transfer to a secure hospital. Segregation should be avoided for such prisoners, unless there are clearly recorded exceptional circumstances.

Dual Diagnosis

Lesson 21: Mental health and substance misuse teams should work together to provide a coordinated approach to prisoner care. This should involve the use of agreed dual diagnosis tools to assess prisoner needs and regular meetings to discuss and plan joint care.

Lesson 22: Details of all interventions from substance misuse services should be recorded in a prisoner’s SystmOne health record.

Lesson 23: Prisoners undergoing treatment for substance misuse should not be prevented from accessing secondary mental health services.

Personality Disorder

Lesson 24: When a prisoner is moved to a standard prison wing, from a secure mental health hospital or a specialist prison unit for those with severe personality disorder, their reintegration should be supported and their progress monitored. They should initially be allocated a healthcare practitioner with experience of personality disorder and be given appropriate care in line with an agreed care plan.

Lesson 25: The risks presented by all offenders with severe personality disorder who face long periods in prison should be identified and managed through informed sentence planning and suitably structured regimes.

Personality disorder is a recognised mental disorder, but differs from a mental illness. Mental illness is generally regarded as a change to an individual’s usual personality, which can be treated, and their usual personality returned. Personality disorder relates to the way an individual is psychologically constructed. Their usual personality is extreme, therefore there is no illness to get rid of and no ‘normal’ personality to return to. Instead, treatments for personality disorder aim to help the person control and manage their abnormal personality.


The PPO Thematic review ends with this conclusion:

“There has been significant movement in policy and practice surrounding the approach to managing mental health needs of prisoners over the last two decades, and some improvement has undoubtedly been made. However, there is still a long way to go, and we hope that the lessons identified in this report can help prisons to re-evaluate and improve their practices where appropriate, amid the complex landscape of mental health provision.”

Perhaps this conclusion goes beyond the prison walls and out into the wider criminal justice sector whereby other alternatives could and should be made available to the courts and the liaison and diversion teams who work within them.

Custodial environments should be considered as a place last resort for those suffering from mental health issues, rather than the default setting as perhaps it currently is.


PPO Thematic Review Mental Health

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