Health Notes from IMB Reports – August 2019 (Pt.2)

The IMB reports published during the latter part of August 2019 were from these establishments:

  • HMP/YOI Rochester
  • HMP Frankland
  • HMP Moorland
  • HMP North Sea Camp
  • HMP Pentonville
  • Dungavel House IRC
  • HMP/YOI Portland
  • Morton Hall IRC

IMB evidence comes from observations made on rota visits, scrutiny of records and data, attendance at various meetings, informal contact with staff and prisoners, prisoners’ applications and monitoring of areas of concern.

Here are some of the more interesting points contained within those reports, pertaining to health and wellbeing:

IMB Report – HMP Rochester

Reporting period – 01 Apr 2018 to 31 Mar 2019.

  • Staff shortages noted within the healthcare team, but remains a team of dedicated nurses at the prison, often working additional hours and exceeding what is expected of them.
  • Strained relations between the healthcare provider and the prison, although recent improvements were noted. Prison officers are now in attendance at all clinic sessions, but there are still occasions when wing officers fail to deliver appointment slips to prisoners until it is too late to attend.
  • There is the ongoing of medication being concealing by prisoners, presumably for trading. When identified, such prisoners are referred to the GP for review; as too are those who fail to collect medication regularly or are found to be non-compliant as a result of wing-based medication checks.
  • Delays in outpatient appointments remain, due to a lack of officers being available for escort duty, although it is noted to have improved during the year. As the availability of NPS remains significant in the prison, its effects are the cause of a significant proportion of the emergency A & E call-outs.
  • There were 176 complaints to Healthcare – primarily about medication and external hospital appointments, which is the same position as last year. Complaints to the IMB usually relate to perceived delays in appointments to see GPs or a hospital visit and are generally resolved.
  • An Optician visits the prison every fortnight, and there is a long waiting list. The growing profile of elderly prisoners with deteriorating eye sight adding to this pressure.
  • At time of writing this report, the IMB noted that substance misuse services are supporting 179 prisoners in structured treatment, a further 40 are given unstructured treatment, and 85 are on Opiate Substitution Therapy (OST).
  • Mental health services have a caseload of 77 patients with a 43 referrals in process. The IMB is noting that with the focus on opening up about mental health issues, the team at Rochester are spending more time and energy is helping with prisoners with their mental health issues.
  • Healthcare applications to the IMB increased to 42 from 40 when compared to the previous reporting year.

Full IMB Report – HMP/YOI Rochester

IMB Report – HMP Frankland

Reporting period – 01 Dec 2017 to 30 Nov 2018.

  • Reported self-harming incidents rose to 560 carried out by 83 prisoners compared with 403 carried out in the previous year. At the time of writing HMP Frankland has adopted a new SASH (Suicide and Self-Harm) policy which aims to reduce incidents of self-harm and deaths in custody.
  • The Governor is introducing a specialist into the Segregation Unit to monitor Mental Health issues and has deployed a Nurse Station in the Unit full time.
  • Recruitment of nursing staff continue to cause issues which reflects the national problem.
  • The focus of clinical and professional improvement noted by the CQC was the unmonitored fridge temperatures where drugs are stored, clinical supervision and staff training. Training is now evidenced and continually updated through a combination of face-to-face courses and on-line updates.
  • Although the Healthcare team have been through a particularly difficult year, the staff have engaged well and a tracking system of audits shows discernable improvement indicating a well-led service.
  • There continues to be considerable challenges in Healthcare, in caring for patients who have mental health conditions or non-medical issues who are lodged in Healthcare (in-patients) and could be returned to the wings were they not considered to be too disruptive.
  • An emerging dimension of healthcare for the long term high secure estate (LTHSE) is dealing with long term conditions such as dementia and a range of chronic diseases. Future development of services requires easy access to secondary care expertise to support both patients and staff. This certainly will need innovation and resource to meet this growing challenge. Training for prison staff needs consideration as part of this service development.
  • Overall, waiting times have improved across the range of services offered. Part of the solution is to challenge prisoners to use the telephone lines to cancel appointments and reduce ‘did not attend’, so appointment lists can be managed effectively. If prisoners use the telephone lines correctly, they can seek advice on healthcare issues without necessarily needing a GP appointment. There appears to be a confidence in prisoners using this service and improvements continue.
  • The Patient Consultative Committee (PCC) for Healthcare has been regenerated by the Clinical Lead and has become a focussed meeting actively seeking prisoner engagement. Following the CQC visit, the prisoners have been asked to contribute to the service review so healthcare services are ‘fit for purpose’. After initial hesitancy and some negativity, the meeting is going from strength to strength with a far more ‘can do’ attitude and honest dialogue.
  • A long term problem within Healthcare is the unacceptable waiting times prisoners experience when attending out-patient appointments. At the time of writing the report, the Governor has approved two posts who are effectively ‘Move Officers’ who can move prisoners back to their wings in order to tackle this problem. Priority transfer will be given to prisoners who are going to education or work so they do not miss out on morning or afternoon activity.
  • Healthcare applications to the IMB remained unchanged with 15 when compared to the previous reporting year.

Full IMB Report – HMP Frankland

IMB Report – HMP Moorland

Reporting period – 01 Mar 2018 to 28 Feb 2019.

  • HMP Moorland has benefited financially this year by being nominated as one of the prisons in the 10 prison project (10PP). The focus of this programme is on improving decency, leadership and the reduction of violence and drug-use within the prison.
  • Notable statistics for this reporting year include: 578 ACCT documents opened, 755 incidents of self-harm, 45 constant supervisions, 198 prisoner-on-prisoner assaults and 119 assaults on staff.
  • Mental health staffing has been increased so that care is now available 7 days per week, and prisoners put on an ACCT can be seen within 24 hours.
  • The overall cancellation rate for hospital escorts reduced to 8.1%, which equated to 62 cancellations from the 769 that were planned.
  • The number of psychoactive substance (PS) incidents have significantly decreased over the year, most likely as a result of the 10PP investment and additional resources. This reduction means that the 1–1 interventions with the Substance Misuse team are now more effective.
  • Overall the IMB is satisfied that healthcare services including mental health, substance misuse, and the arrangements for social care are of a standard equivalent to those available to the general population.
  • Healthcare applications to the IMB increased to 52 from 29 when compared to the previous reporting year.

Full IMB Report – HMP Moorland

IMB Report – HMP North Sea Camp

Reporting period – 01 Mar 2018 to 28 Feb 2019.

  • HMP North Sea Camp has adopted a rehabilitative culture and now refers to the prisoners as residents.
  • The Board is satisfied that healthcare provision at the prison is generally of the equivalent standard to that provided outside prison and, in some cases, exceeds it.
  • Typical waiting times for residents seeking medical attention are generally seen the same day by a triage nurse, and within a modern healthcare facility. GP appointments are facilitated within about a week. Optometry waiting time is within 4 weeks. Residents requiring urgent access to mental health services are seen within the same day. Residents are referred for screening programmes such as abdominal aortic aneurysm (AAA) screening and diabetic retinopathy screening within the same timescales as in the community.
  • The Board is pleased to note that the health provider continues to provide the finance to employ 4 extra prison officers to escort residents to hospitals and for bed watches when required. This has made a considerable difference to residents’ treatment in that appointments rarely have to be cancelled and rearranged. Escort duties no longer negatively impact on the prison regime which was the case in the past.
  • There are plans for the extension of the Healthcare centre during the 2019/20 financial year with funding from NHS England.
  • At periods throughout the year, and particularly for the compilation of this report, Board members have sought the opinions of the residents as to the standard of healthcare they receive. Whilst there are on occasion some complaints, and 12 healthcare-related applications to the IMB, in the main their opinion is favourable. One resident said recently of his treatment, leading to a surgical operation, that he was “impressed and delighted” with the service he had received, particularly by the staff at the Healthcare centre.
  • The percentage of residents over 50 years of age has increased and continues to do so. The health needs of an older population are well documented. Long term chronic age related issues include COPD, diabetes, cancers, mobility problems, arthritis, anxiety and increased comorbidity (2 or more long-term conditions). There is also an increase in those registered as “disabled”.The Board considers that the prison currently meets the healthcare needs of the population. However, going forward, it is likely that there will need to be more healthcare staff to service the increasing healthcare needs of an ageing prison population.
  • A small but very efficient unit of two mental health nurses provides an excellent service. There is an open-door policy and “nobody is ever turned away” from seeking help at the door. The team are part of the Quality Network for Prison Mental Health Services (QNPMHS) – the national peer review quality network. At the annual reviews for the last two years they were rated as the best MH team in the country, when rated against other participating prisons.
  • However, this small team have a heavy personal caseload and a lack of support. Between the two of them they currently have a combined personal caseload of over 50 patients. During the year to end of February 2019, the team dealt with a combined caseload of 224 patients. In addition, they run mental health awareness days, and give ongoing support to other patients in conducting “wellbeing interviews” There is currently no patient waiting list to see a mental health professional.
  • At the time of reporting, 22% of the residents at this prison are classed as “disabled” in some way and 30 residents have a personal emergency evacuation plan (PEEP) in place to assist them to leave their rooms safely in the event of an emergency. The prison has recently formed a team of five “residential support workers” – residents who are employed to support 20 disabled residents who are on PEEP plans.
  • In previous reports, the IMB have raised concerns about certain aspects of healthcare. The provision of dentistry has been addressed by the introduction of a mobile dental van (since Nov 2018). Residents get to see a dentist quite quickly now (within 4 weeks typically) for an initial assessment; however, there is typically a 10 week wait for treatment unless the resident is in severe pain or has a deep infection. Credit is given to the clinical lead at HMP North Sea Camp who has fought hard to get this service provided.
  • Healthcare applications to the IMB decreased to 12 from 15 when compared to the previous reporting year.

Full IMB Report – HMP North Sea Camp

IMB Report – HMP Pentonville

Reporting period – 01 Apr 2018 to 31 Mar 2019.

  • One recorded self-inflicted death this year compared with 3 and 6 deaths respectively for the last two years, bucking the national trend.
  • ACCT numbers have risen from 709 to 742 reflecting a trend seen across the prison estate since the introduction of Key Workers – a scheme carving out regular dedicated time for officers to support prisoners and pick up on issues – and the influx of newly trained officers. Many ACCTs are able to be closed within a day once immediate concerns are addressed.
  • Reported incidents of self-harm have increased this year to 598 from 500 in the previous year.
  • Mental health staff cannot always attend initial ACCT case reviews. Although a nurse is allocated Monday – Friday for this duty, the reviews are not well coordinated by the prison.
  • All health referrals are considered at a daily meeting of the Wellbeing team (Primary Care, In Reach Mental Health, the Wellbeing Centre, and Building Futures). This ensures co-ordination of provision and prevents time wastage by misdirected referrals.
  • The outstanding Wellbeing Centre has strong leadership and a motivated team. Largely refurbished, the services now include activities such as cooking and baking. Users are very enthusiastic about the activities and the staff.
  • National policy to return prisoners from secure psychiatric units to the nearest prison means that Pentonville receives a disproportionate number of such prisoners, putting pressure on the prison’s mental health services.
  • Wellbeing Centre staff continue to report that ACCT documents are not always sent across with prisoners.
  • No dedicated rooms on the wings for mental health staff to use for assessments means interviews take place in difficult conditions with little privacy.
  • A substance misuse through-the-gate worker may accompany an offender to key appointments on release and keeps in touch for up to three months.
  • Last year, the Board said it should be a prison priority to ensure that misusers go to the designated wing where extra medical support is available. The risk to life of alcoholics in first days of detox is acute. However, some men are still scattered across the prison endangering life.
  • Healthcare applications to the IMB decreased to 73 from 114 when compared to the previous reporting year.

Full IMB Report – HMP Pentonville

IMB Report – Dungavel House IRC

Reporting period – 01 Jan 2018 to 31 Dec 2018.

  • The numbers detained at Dungavel dropped significantly during the reporting year. This was in line with other establishments throughout the Immigration Estate.
  • The capacity of the Centre is 249. This is made up of 235 male beds, 14 female including the 3 disabled beds.
  • There were 21 detainee-on-detainee assaults, and 3 detainee-on-staff assaults and during the reporting period.
  • There is no medical recording IT system in the Health Centre. This results in an increased amount of clinical time being spent dealing with paper files. The Scottish Prison Service do not always pass on medical notes for Time Served Foreign National Offenders (TSFNOs).
  • Detainees are seen by a nurse within two hours of admission and offered an appointment with a doctor within 24 hrs. The health centre has open access but all further requests for an appointment are triaged by a nurse and detainees can then see a doctor within 24 hours. Medication is dispensed three times a day with an officer in attendance.
  • The mental health team help with anxiety, relaxation and anger management where detainees are having difficulty coping with situations in detention. They also run a horticultural group.

Full IMB Report – Dungavel House IRC

IMB Report – HMP/YOI Portland

Reporting period – 01 Apr 2018 to 31 Mar 2019.

  • The Board’s concerns regarding healthcare provision in general have changed little over a number of years. They involve issues about the way the prison facilitates the delivery of healthcare services as well as aspects of service provision delivered by the health provider. Whilst the senior management team and the healthcare lead are alert to the issues, there has been improved collaboration between the two services, but the IMB view is that access to the services provided in Portland are still not on a par with services in the community.
  • A service user forum has been established for the first time this year.
  • A seemingly intractable problem impacting on the smooth and safe delivery of healthcare services, is the timely, efficient and effective dispensing of medicines. Until recently facilitating the dispensing of medication was not a profiled duty for operational staff on the wings. The result was that, despite the fact that 25% of the population are in receipt of daily medication and between 50–60 prisoners, at any one time, are on a methadone script, no officer was allocated the responsibility of escorting prisoners to and from the dispensary in the healthcare building.
  • Deficiencies in the deployment of operational staff to provide support for the delivery of health and social care services are being addressed, but there is little evidence that the time taken to dispense medicines has improved. The knock-on effect is that subsequent clinics run late, have to be curtailed or are cancelled so prisoners face significant delays in accessing appointments with specialist service providers.
  • The Board continues to have concerns about the profile of the healthcare team. A shortfall in mental health staff and difficulties appointing and retaining staff means that the limited resource has to be focused on mental health assessments. As a consequence, treatment is based on drug therapy rather than psychosocial support as a treatment for mentally disordered prisoners.
  • At the time of writing of the report, there was no psychiatrist in post on the mental health team, although one had been appointed. The nursing complement does not appear to be adequate for the requirements of the prison. It is currently taking 5 weeks to access a mental health appointment. Although this year has seen an improvement, staffing shortages mean that segregation and ACCT reviews take place without a mental health or other health representative, or are attended by a staff member who has minimal knowledge of the prisoner.
  • Mental health data for July and August 2018 evidenced that in the respective months only 190 out of 313 (61%) and 157 out of 252 (62%) were brought for their appointment. Prisoners and wing staff are alerted to appointments by healthcare the day before via an appointment slip. In December a wodge of these undelivered appointment slips was found in waste management.
  • More recently changes to the funding of substance misuse services from the Prison Service to NHS public health teams have seen some downgrading of its priority. This will have a significant impact on the service, which holds an average caseload of 200 prisoners at any one time.
  • Healthcare applications to the IMB increased to 27 from 23 when compared to the previous reporting year.

Full IMB Report – HMP/YOI Portland

IMB Report – Morton Hall IRC

Reporting period – 01 Jan 2018 to 31 Dec 2018.

  • The operational capacity of Morton Hall is 391 detainees. For much of 2017 the centre operated nearly at full capacity. However, in keeping with other IRCs, the roll fell significantly during 2018; the average figure for the year was 293.
  • The average length of time detainees spent at Morton Hall during 2018 was between 2 and 4 weeks.
  • Healthcare provision at Morton Hall continues to build on the former HMIP/CQC Inspection reports with respect to strong clinical leadership, an effective team approach, an integrated service, sound governance and a good partnership with the centre’s management team.
  • Mental health provision has continued to improve. There has been an increase in the staff component from 3 to 6, now consisting of 2 clinical matrons, 3 senior mental health nurses and 1 mental health nurse.
  • The contribution of the Substance Misuse Practitioners is applauded by the IMB; their service is well used by detainees who often commend its quality and availability.
  • For the second year running the Mental Health Team has been recognised in the Quality Network for Prison Mental Health Services (QNPMHS) Peer Review (2018) as offering a high- quality service, coming second with a score of 91% of standards fully met. The site that placed first (North Sea Camp) has the same healthcare provider.
  • While healthcare is an agenda item on the monthly Residents’ Representative Group’s meetings, detainees feel they have limited involvement in the governance and development of the service. This is possibly a matter for future consideration.
  • Wellbeing Days are held monthly. They continue to be supported by all pathways; primary care; mental health and substance misuse.
  • The healthcare team continues to be proactive with respect to the management of complex cases. Complex case meetings are held every week and attended by everyone on shift, including primary care, mental health, substance misuse and pharmacy.
  • Healthcare applications to the IMB decreased to 11 from 19 when compared to the previous reporting year.

Full IMB Report – Morton Hall IRC

HMIP Health Notes: HMP Forest Bank, May 2019

This report was on an unannounced inspection of HMP Forest Bank between 13,14,20–24 May 2019, and was published in September 2019.

General Points of Interest:

The levels of self-harm had increased significantly since the previous inspection and were concerning. There had been 734 incidents of self-harm by 177 prisoners during the previous six months.

As part of the survey, 63% of prisoners said that they had mental health issues.

51% of prison officers had less than 2 years’ experience, 37% had under 12 months.

In the survey, 61% of prisoners said it was easy to get illicit drugs at the prison and 26% said that they had developed a drug problem while at Forest Bank against the comparator of 16%.

Healthy Prison Outcomes:

2016 2019
Safety 3 2
Respect 3 3
Purposeful Activity 3 3
Rehabilitation & Release Planning 4 4

Outcome Ratings:

Rating Outcomes for Prisoners
4 Good
3 Reasonably Good
2 Not Sufficiently Good
1 Poor

Key Points of Interest: Health, Well-Being and Social Care:

The complaints system was now confidential with work in progress to differentiate complaints more clearly from applications and concerns. Most patients expressed dissatisfaction with medication issues. Written responses to complaints were courteous, timely and apologetic where necessary. Patients could influence health services development through regular user surveys and the monthly consultative meeting.

Clinical leadership (other than in in-patients) was good with experienced staff providing primary care, along with 24-hour nursing cover. Health staff mandatory and further training was very good, and now included safeguarding of adults.

Annual appraisal and managerial supervision arrangements were in place and staff generally felt supported. Clinical supervision was voluntary and not all primary care staff took advantage of it.

Most clinics were held in the health centre where the range of clinical activities had outgrown the space available. The waiting area was well supervised and contained relevant health promotion materials. Patients spent less time there than in 2016. The temporary waiting room facilities for vulnerable prisoners were sparse and unwelcoming.

SystmOne records that we sampled were informative and subject to clinical audit. Audits demonstrated good compliance with information governance standards along with an active programme of other clinical audits ensured compliance with expected standards.

There was a prison-wide approach to health promotion and the multidisciplinary action board met every two months to promote wellbeing across the prison. National health campaigns were promoted by identified staff. Health-related materials were displayed throughout the wings, health care and the gym. Supportive self-help materials were available in the library.

At time of inspection, there were no health champion peer workers, although there were advanced plans to start recruitment.

Opt-out screening and treatment of blood-borne viruses were very effective, supported by good links with a local specialist service. There was good access to age-appropriate immunisations and vaccinations, national screening campaigns, such as abdominal aortic aneurysm and bowel cancer, and smoking cessation.

Initial health screening was undertaken promptly by a registered nurse. Attendance rates at secondary health assessments had improved significantly, ensuring good support during prisoners’ early days. Staff made appropriate referrals to other clinicians from these initial assessments.

The appointments system was effective, although appointment slips were handed to officers without a sealed envelope, which compromised confidentiality.

At the time of the inspection, 355 patients had long-term conditions such as asthma, diabetes or epilepsy and were regularly reviewed by competent staff, with care plans and evidence-based practices.

GP services were available each weekday and Saturdays, and out-of-hours cover had been introduced but was rarely used. Patients had good access to urgent same-day GP appointments and non-urgent appointments within 10 days, which was reasonable.

The did-not-attend (DNA) rate was 16% for the GP, which was an improvement. While DNA rates for some other clinics remained high, innovative ways to engage patients and reduce DNAs had been introduced, such as a clinic in the gym. The range of specialist clinics was good and included physiotherapy, ophthalmics and podiatry, with short waiting lists.

External health care appointments were well managed by an administrator, with clinical input where required. Few were cancelled for security reasons. Telemedicine equipment was installed during the inspection to enable specialist consultations without leaving the prison.

All patients were reviewed before release by a nurse and given any ordered medication to take home, along with advice on accessing community health services and a care summary record. While most released and transferred prisoners left with their required medication, recording of this was inaccurate and ineffective, despite recent measures implemented to monitor and improve compliance.

The inpatient unit remained a poor environment with 19 beds in single and double cells, and one four-bed bay. The unit was stark and sometimes excessively noisy. Bed occupancy ran at about 63%. One bay was in use as a temporary waiting room for vulnerable prisoners attending out-patients, which was not ideal. Prison and health staff were not familiar with the admission criteria, though these were updated and re-issued at the time of the inspection. Between the well-attended weekly multidisciplinary care team meetings, admissions were made to the unit for non-clinical reasons, which was not appropriate.

In the survey, 63% of prisoners said that they had mental health problems. While only 32% said they received help with these problems, inspectors found that mental health provision had improved since the last inspection, despite high demand for support.

The integrated mental health team was well staffed and provided daily support to prisoners, including attendance at ACCT reviews. Three of the registered mental health nurses regularly covered general primary care duties, which affected their capacity to deliver mental health care.

New MH referrals and complex cases were reviewed at an effective weekly team meeting and single point referral meeting with multidisciplinary input.

The waiting list for initial triage appointments had halved since our last inspection. Prisoners could wait up to three weeks for an initial triage appointment, which was too long. Attendance at mental health appointments was good, and staff appropriately followed up those who did not attend.

The in-reach team provided good support to 58 men with more severe mental health conditions using the care programme approach. There was prompt access to the service and prisoners were reviewed regularly, including physical health checks and psychiatric consultations. Clinical records that we sampled contained evidence of responsive and personal care planning and regular risk assessment.

60% of prison officers had received mental health awareness training, which was an improvement since 2016. The psychological wellbeing practitioner had recently started delivering a more detailed training programme for prison staff.

In the survey, 49% of respondents said they had a drug problem on arrival at the prison against the comparator of 34%. At the time of inspection, 402 prisoners were engaged with the Integrated Substance Misuse Services (ISMS) work focused on recovery.

New ISMS referrals were seen within five days and there were robust systems for urgent referrals to be seen promptly. All prisoners arriving in reception were seen by an ISMS worker for assessment. They could see a clinical prescriber if necessary and were given harm reduction advice and materials as appropriate.

Effective multi-agency working between the ISMS, health care and the prison was evident with recorded monthly meetings to share information and intelligence. There was a drug strategy but no action plan (see paragraph 1.53). The prison programme manager was co- located with ISMS team managers which facilitated effective communications.

The governance of the ISMS was very good, compliance with staff mandatory training was excellent, and clinical and managerial supervision was well embedded. Staff we spoke to valued weekly group supervision sessions and felt supported in their roles. A recent prisoner consultation (February 2019) had informed service delivery.

At time of inspection, 192 prisoners were in receipt of methadone opiate substitution therapy (OST) and four were receiving rapid release buprenorphine. The majority (85%) were receiving maintenance doses, which was clinically appropriate. Prescribing was flexible and medicines were administered from G/H wing. We observed a noisy and poorly controlled medication queue, but the risks were addressed immediately when we raised concerns.

About 87% of patients had medicines in possession (50% in 2016). The policy was applied and risk assessments were completed and repeated as necessary. Patients received in-possession medications in health care. There was still no lockable storage for patients to store medicines in their cells safely.

The small number of tradeable medications being prescribed was impressive, reducing the risks of bullying. However, many prisoners complained that they were not receiving medicines that their GPs prescribed in the community.

Nurses administered medicines up to three times a day at appropriate times. The medicines queue at the administration room on the A-F hub was congested but well supervised. Patients sometimes experienced delays in receiving their medicines, causing gaps in their treatment, but many did not request repeat prescriptions despite reminders to do so.

As part of the survey, 30% of prisoners rated the overall quality of the health services as being either very good or quite good.

Recommendations: Health, Well-Being and Social Care:

  • Appointment slips for health appointments should be distributed in a way that preserves the patient’s confidential medical status.
  • All prisoners should be released or transferred with their required medication, and this process should be recorded accurately and regularly monitored.
  • Patients requiring mental health inpatient care should be transferred within the national guidance timeframe.

Good Practice: Health, Well-Being and Social Care:

  • The novel introduction of a nurse-led clinic in the gym enabled patients who preferred to attend the gym to access health care. Long-term condition monitoring was improved by arranging health checks in the gym.
  • Integrated substance misuse services (ISMS) workers were aligned with identified community services which created a ‘virtual’ through-the-gate team ensuring seamless, collaborative release planning and aftercare.

CQC Requirement Notices Issued:

  • None


Full Report Here – HMP Forest Bank

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

HMIP Report Health Notes: HMP Eastwood Park, May 2019

This report was on an unannounced inspection of HMP Eastwood Park between 03–17 May 2019, and was published in August 2019.

“On entering these units, I was immediately struck by the sight of rows of women’s faces pressed against the open observation hatches of their locked doors, peering out into the narrow, dark, cell block corridor. It was as if they were waiting for something or indeed anything to happen, however mundane, to relieve the monotony of their existence.”
– Peter Clarke, HM Chief Inspector of Prisons

General Points of Interest:

73% of prisoners told inspectors that they had mental health problems, and 48% had problems with illicit drug use. These issues were compounded by the fact that many women were serving short sentences of less than 6 months – clearly reducing the opportunity for effective interventions.

43% of prisoners were in custody for the first time, and 33% had served five sentences or more. 36% of prisoners had been at the prison for less than 3 months.

In the previous 6 months prior to the inspection, there had been 120 reported assaults and 578 incidents of self-harm.

Healthy Prison Outcomes:

2016 2019
Safety 3 3
Respect 3 3
Purposeful Activity 3 3
Rehabilitation & Release Planning 3 2

Outcome Ratings:

Rating Outcomes for Prisoners
4 Good
3 Reasonably Good
2 Not Sufficiently Good
1 Poor

Key Points of Interest: Health, Well-Being and Social Care:

The service was well led, supported by skilled clinical leads, and we observed conscientious staff who knew their patients well. Mandatory training was well managed, and professional development was identified and encouraged through regular managerial and clinical supervision and appraisals.

Effective patient engagement, with regular health improvement groups and surveys, had influenced service delivery improvements.

Prisoners had access to a secure separate health care complaints system. Sampled responses were respectful in tone and fully addressed the issues highlighted. However, response times and oversight were not managed well enough, as some fell outside of the recommended timescales. Compliments received were shared with staff.

Health promotion formed an integral part of the prison’s well-being strategy, and local and national well-being initiatives were well advertised.

Smoking cessation support was available for those who wished to stop nicotine vaping, but uptake was low.

New arrivals received a comprehensive initial health screen with a nurse, focusing on risks and immediate needs, including those relating to substance use withdrawal, pregnancy, mental health and self-harm. Secondary health screenings were booked promptly, to identify and address prisoners’ health needs immediately. Good liaison with community services helped to ensure continuity of care.

Waiting times were short, with a 3–4 day wait for a routine GP appointment, and urgent appointments facilitated on the same day.

A weekly multidisciplinary complex case meeting was effective at ensuring that concerns were identified and discussed, and solutions explored to maintain well-being.

During the inspection, only around 25% of prisoners prescribed medication received it in- possession, following an appropriate risk assessment. This relatively low level of in-possession medication led to particularly busy morning and evening administration sessions. This was partially due to a lack of secure in-cell storage, which the prison was addressing.

The recent change in the classification of pregabalin and gabapentin to controlled drugs from April 2019 had caused minimal disruption owing to the proactive approach to the management of pain. The service had introduced a pregabalin reduction programme, which offered support to help prisoners to reduce their dependency gradually, ensuring that they were on clinically appropriate medication.

Refrigerator temperatures were recorded well in most treatment rooms but there were some gaps. Inspectors also found another refrigerator for which the temperatures had not been recorded, which meant that the integrity of the medicines stored within it could not be assured. This issue was addressed during the inspection.

The teams were based in an open-plan office, which promoted effective communication and integrated work between the physical and mental health care teams.

The average number of referrals into the Mental Health service was approx. 135 per month and the team was currently supporting 152 patients (approximately 40% of the population) via individual and group sessions.

A crisis team, made up of registered and support staff, responded promptly to urgent referrals, including attendance at all initial assessment, care in custody and teamwork (ACCT) case management reviews, and worked from 8am to 8pm, seven days a week. The caseload was usually between 30 and 40 and was actively monitored and reviewed throughout the day. One or more sessions were offered, and referrals to other parts of the service were made, dependent on need.

The primary care mental health team consisted of two experienced registered mental health nurses, who were also non-medical prescribers and held regular clinics. Although the waiting time was at around 4 weeks, the crisis team offered support, and prioritised accordingly.

Prisoners attended a pre-discharge health clinic a few weeks before, and on the day of, release, to check their general health and welfare. A GP summary was provided; if the prisoner did not have a GP, they received information about the services available in the area they were being released to. Take-home medication was supplied.

Substance Misuse service provision was delivered by two separate providers – one for psychosocial support and the other for clinical services. Inspectors noted that although information sharing between substance use services had improved, teams were not yet fully integrated. Clinical and psychosocial substance use teams did not complete prescribing reviews jointly, and this was a missed opportunity to coordinate treatment and maximise support.

The substance use team contributed to the discharge board, and a continuity of care worker liaised with community prescribers and ensured treatment continuation on release. Naloxone training for relevant prisoners before release, to treat opiate overdose in the community, was well established but the provision of harm reduction information was not systematically recorded and evidenced. A designated through-the-gate worker maintained good links with community teams.

Dental appointments were appropriately prioritised according to clinical need, and sessions offered a range of treatment, equivalent to that in the community. Urgent referrals were seen promptly, but waiting times for routine appointments were too long, at around 11 weeks.

As part of the survey, 54% of prisoners rated the overall quality of the health services as being either very good or quite good.

Recommendations: Health, Well-Being and Social Care:

  • Substance misuse services should be fully integrated, and a range of group work and mutual aid support should be available to prisoners, independent of location.
  • Those with complex health needs should have recorded care plans that are reviewed regularly.
  • Prisoners should have access to routine dental appointments within 6 weeks. (A repeated recommendation)
  • The substance misuse team should systematically record and evidence the provision of pre-release harm reduction advice and information.

Good Practice: Health, Well-Being and Social Care:

  • Prisoners with specific health issues were encouraged to participate in well-advertised fitness programmes which were tailored to meet individual needs.
  • The introduction of the social prescriber role was a positive initiative, providing additional assistance for patients and links with other services promoting health and well-being

CQC Requirement Notices Issued:

  • None.


Full Report Here – HMP Eastwood Park

World Suicide Prevention Day – The Vera Report into Sentinel Events

Following on from last week’s post, I’ve been curious to understand how preventing suicide in places of detention is applied in another country outside of the UK. I was drawn to the US Correctional System and found this report by The Vera Institute of Justice to be of interest. An insightful read.

The Vera Institute of Justice is a justice reform change agent. Vera produces ideas, analysis, and research that inspire change in the systems people rely upon for safety and justice, and works in close partnership with government and civic leaders to implement it.

Vera is part of an expanding group of researchers and practitioners supported by the National Institute of Justice that seeks to understand the feasibility, impact, and sustainability of adopting sentinel event reviews in the criminal justice system.

This report is the second from Vera that frames suicide and self-harm in correctional facilities as “sentinel events” that signal a breakdown in underlying systems of care. Sentinel event reviews have been used successfully in the field of medicine for decades and have much to offer the US Corrections community.

Based on principles of transparency, inclusiveness, and systemwide accountability, sentinel event reviews acknowledge that bad outcomes are rarely the result of an individual mistake and embrace a forward-looking approach to safety. Put into practice in jails, they are one important step toward implementing a comprehensive suicide prevention plan.

Background and Context

Each year, more than 300 people take their lives while incarcerated in America’s jails, accounting for roughly one-third of all deaths in custody and therefore making suicide the leading cause of death. Approximately one-quarter of these deaths occur within 24 hours of confinement and half occur within the first two weeks. When I think of American jails, the obvious comparrison for prisons in England and Wales are those local prisons.

In 2014, the rate of suicide in local jails (50 per 100,000 people) was the highest observed since 2000 and remained more than three times higher than rates of suicide in either prison (16 per 100,000) or in the community (13 per 100,000). Although the rate of jail suicide dropped dramatically between 1986 and its low point in 2008 (from 107 to 29 per 100,000 people), the rate has since fluctuated between 40 per 100,000 and 50 per 100,000.

In 2016, the Vera Institute of Justice (Vera) reported on the potential for addressing the problem of jail suicide and self-harm through “sentinel event reviews.” Recognizing that failures to prevent jail suicide or self-harm are rarely the result of a single event or the actions of an individual staff member.

Conducting a Sentinel Event Review

A sentinel event is defined by American healthcare accreditation organization The Joint Commission (TJC) as any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient’s illness. Sentinel events specifically include loss of a limb or gross motor function, and any event for which a recurrence would carry a risk of a serious adverse outcome. Sentinel events are identified under TJC accreditation policies to help aid in root cause analysis and to assist in development of preventative measures.

Sentinel event reviews take a “root-cause analysis” approach, guiding practitioners through the following eight steps:

  1. identify the sentinel event;
  2. gather a multidisciplinary team;
  3. describe the event/create a timeline;
  4. identify contributing factors;
  5. identify the root cause(s);
  6. develop an action plan;
  7. share lessons learned; and
  8. measure the success of corrective actions.

National Standards on Suicide Prevention in Jail

National Commission on Correctional Health Care (NCCHC) standards are the most widely used guidelines for health care delivery in jails. These standards include both clinical and non-clinical practices to identify people who are at risk of suicide, develop treatment plans, and identify process improvements. NCCHC standards explicitly delineate 11 key components necessary for a comprehensive suicide prevention program:

  1. training;
  2. identification;
  3. referral;
  4. evaluation;
  5. treatment;
  6. housing and monitoring;
  7. communication;
  8. intervention;
  9. notification;
  10. review (see below); and
  11. debriefing.

Recommended Review Processes

NCCHC’s standards recommend three distinct reviews following each death in custody in order to identify areas where facility operations, policies, and procedures can be improved. These reviews are:

  • an administrative review assessing the correctional and emergency response;
  • a clinical mortality review answering three questions: (1) could the medical response at the time of death be improved?; (2) is there any way to improve patient care?; and (3) was an earlier intervention possible?; and
  • a psychological autopsy if the death is by suicide
    (a reconstruction of the individual’s life and factors that may have contributed to death, conducted by a qualified mental health professional).

Even with such standards in place, Vera notes that the NCCHC provides little guidance on how to implement the various aspects of a suicide prevention program. Policies and practices therefore look markedly different across the jails and, in fact, research suggests that only 20 percent of jails have a suicide prevention program that covers all key components.

Key Recommendations: Responses to Suicide and Self-Harm

Develop suicide prevention plans consistent with national standards. Even jails that are not accredited can follow guidance available from the NCCHC or the American Correctional Association (ACA) to develop suicide prevention plans that address the 11 key components of robust suicide prevention programs.

  • Seek out guidance on conducting robust reviews. The health care and criminal justice fields have helpful guidance on how to implement an all-stakeholder, nonblaming review process in the aftermath of a death.a This practical guidance provides concrete steps to take and information on how to overcome implementation challenges.
  • Consistently review incidents of non-lethal self-harm, i.e the “near-misses.” Most reviews focus on suicide, and sometimes suicide attempts, with less clear criteria on when cases of self-harm warrant a review. Given the prevalence of self-harm compared to less frequent incidents of suicide, this may be a missed opportunity to strengthen practices and policies to prevent suicide and self- harm on a more regular basis.
  • Training on suicide and self-harm prevention should include corrections and health staff together—in person—to foster collaboration and learning across disciplines.
  • Particularly for jails that contract out their health care delivery or have multiple agencies providing health care, review processes should be consolidated and outcomes should be communicated to both corrections and health leadership and staff.

When it comes to collaboration and communication, 2 themes emerged through Vera’s study as especially relevant in this regard: (1) the relationship between corrections staff and health staff; and (2) the extent to which information is communicated across disciplines, as well as both up and down the chain of command.

Key Recommendations: Communication and Collaboration:

  • Corrections and health leadership should work together to institute review processes that include stakeholders from all disciplines and levels, with a focus on disseminating findings and recommendations to staff who are in the position to implement corrective actions. Including line staff who work directly with people who are incarcerated, such as nurses, mental health and social workers, and corrections officers, may help identify system weaknesses that would otherwise be overlooked.
  • Review processes for suicide and self-harm must establish clear feedback loops to communicate findings and recommendations to all staff. Increasing transparency in the review process can also facilitate understanding of the full purpose of the reviews, which in turn can encourage candor during the information- gathering phase.

Key Recommendations: Organizational Culture

  • Encourage leadership to actively demonstrate its commitment to focusing on system weaknesses and addressing root causes, not individual errors and staff; this will foster trust and candor during review processes.
  • During the review process, build in opportunities for review team members to express their misgivings about the process and work through conflicts.
  • Use trainings on mental health, suicide, and self-harm to develop capacity among staff and overcome the belief that some suicides are not preventable.
  • Highlight positive changes that result from review processes to encourage openness to change.

Key Recommendations: Legal

  • Do not be dissuaded from conducting reviews because of concerns around sharing personal health information. These issues may limit the depth of information available to all review team members, but should not prevent reviews from taking place at all.
  • Work with legal counsel to understand the protections that exist in state law.
  • Champion the value of a sentinel event review process even in the face of liability, not only for improving practices around suicide and self- harm—which is an important goal on its own— but also as way to proactively avoid harm and contain liability.


Despite the formidable obstacles, research and guidance from experts demonstrate that it is possible to forestall suicides in custody with a comprehensive suicide prevention program—one that includes addressing regular training of all staff, screening and assessment for suicide risk, communication procedures, housing commensurate with risk level, reporting, and multidisciplinary review processes.

“Jails that adopt sentinel event reviews will not only demonstrate leadership and commitment to advancing the field of suicide and self-harm prevention, but will also help instill a new culture in their facilities—one that promotes the safety and well-being of the people in their custody, as well as those who work there.”

10th September marks World Suicide Prevention Day (WSPD) – an awareness day observed, in order to provide worldwide commitment and action to prevent suicides.

The International Association for Suicide Prevention (IASP) collaborates with the World Health Organization (WHO) and the World Federation for Mental Health (WFMH) to host the World Suicide Prevention Day.

Vera – Preventing Suicide and Self-Harm in Jail

Photo by Emiliano Bar on Unsplash

HMIP Health Notes: HMP Pentonville, Apr 2019

This report was on an unannounced inspection of HMP Pentonville between 01–12 April 2019, and was published in August 2019.

“Pentonville epitomises the challenges confronting ageing, inner-city prisons with transient populations, many with heightened levels of need and risk.”

General Points of Interest:

Use of force had been applied 419 times in the 6 month period prior to the inspection.

At the time of this inspection, 25% of the population were receiving psychosocial support for substance misuse needs.

During this same period, the positive MDT rate was 29% for those prisoners tested.

Since the last inspection in 2017, there had been 4 self-inflicted deaths, and another from natural causes.

There had been 316 incidents of self-harm in the previous 6 months, similar to comparator prisons. Constant supervision had been used 17 times.

Over the same period, 400 prisoners had been subject to ACCT processes. 30 of all ACCT documents were opened in reception.

Healthy Prison Outcomes:

2017 2019
Safety 1 1
Respect 2 2
Purposeful Activity 2 2
Rehabilitation & Release Planning 3 2

Outcome Ratings:

Rating Outcomes for Prisoners
4 Good
3 Reasonably Good
2 Not Sufficiently Good
1 Poor

Key Points of Interest: Health, Well-Being and Social Care:

Healthcare managers provided strong leadership to a dedicated professional team who told inspectors that they felt well supported.

Staffing levels and retention had improved, with limited reliance on bank and agency staff. Staff received regular managerial and clinical supervision, and compliance with mandatory training was good. Staff were also supported in developing advanced clinical skills.

The introduction of a dedicated prison governor, custodial manager and prison officers into health care had improved communications and facilitated better access for patients. Patients no longer had to wait in health care for a long period after their appointments and waiting lists were shorter.

The DNA rate for the GP clinic had improved at 10% but remained too high for other clinics, for example dentist 31.8% and optician 35.8%. However, there were plans to deliver more treatment on wings from May 2019 to address this.

There was no overarching health promotion strategy or action plan. Health promotion literature was available in the health centre but limited elsewhere, which was a missed opportunity to encourage well-being.

Working relationships between prison and mental health staff were mature. The majority (97%) of recently appointed prison officers had received some training in mental health awareness, which was viewed by inspectors as being commendable.

There was an open MH referral system, daily well-being team meetings and prompt assessment via the Health and Wellbeing Model. Prisoners in the red zone were seen within one working day and those in the green within 5 days, which was efficient.

The impressive well-being centre continued to deliver an additional level of primary mental health care, supporting vulnerable prisoners through structured and consistent daytime therapies. All eligible prisoners could now use this service, from which 20 prisoners benefited each day.

Patients had complex emotional and mental health needs. About 220 (20%) patients at a time were on the caseload for primary mental health care and 60 (5%) for secondary mental health care. About one in nine prisoners (146) were on anti-psychotic medication which, although less than in 2017, was very high.

At the time of the inspection, 116 patients were receiving methadone or buprenorphine (opiate substitutes), with 54 appropriately on reducing doses. Prescribing was flexible and based on national clinical guidance.

At the time of the inspection, 31% of patients had their medicines in possession. Cells still lacked lockable facilities for storing medicines, but random checks of 10 cells a month had been introduced, which was a noted improvement on 2017.

As part of the survey, 30% of prisoners rated the overall quality of the health services as being either very good or quite good.

Recommendations: Health, Well-Being and Social Care:

  • The prison health care local delivery board should ensure that assertive action is taken to enable access to health care, safe storage of in-possession medicines, and a prison-wide strategy for health and well-being.
  • Governance procedures should be strengthened significantly to ensure safe and appropriate social care provision.
  • Patients requiring care in external mental health services should be transferred expeditiously.
  • Maximum and minimum temperatures should be recorded daily for refrigerators where medicines are stored and documented corrective action should be taken when temperatures fall outside the 2–8 degrees centigrade range.

Good Practice: Health, Well-Being and Social Care:

  • The dedicated team of prison staff in health care had improved efficiency and the patient experience.
  • The well-being centre supported vulnerable prisoners with a structured therapeutic regime and enabled positive outcomes for those with both primary and secondary mental health needs.
  • The enhanced support service team offered valued guidance and support.

CQC Requirement Notices Issued:

  • None


Full Report Here – HMP Pentonville

World Suicide Prevention Day – Resources for Custodial Settings

On 10th September, the International Association for Suicide Prevention (IASP) collaborates with the World Health Organization (WHO) and the World Federation for Mental Health (WFMH) to host the World Suicide Prevention Day.

World Suicide Prevention Day (WSPD) is an awareness day observed on 10 September every year, in order to provide worldwide commitment and action to prevent suicides. Various activities have been taking place around the world since 2003.

The timing seems only appropriate that we consider the guidelines published in September 2018, when the National Institute for Health and Care Excellence (NICE) produced the guidance Preventing Suicide In Community and Custodial Settings.

Of the many organisations for which this guidance was intended, none are more relevant than those of us working in:

  • Prisons (both public and contracted out),
  • Children and young people’s secure estate,
  • Immigration Removal Centres (IRCs), and
  • Probation and Community Rehabilitation Services

High Suicide Risk

NICE determine that “High Suicide Risk” means that the rate of suicide in a group or setting is higher than the expected rate based on the general population (in England). Groups at high risk can include: young and middle-aged men, people who self-harm, people in care of mental health services, family and friends of those who have died by suicide, people who misuse drugs or alcohol, people with a physical illness, particularly older adults, people in the LGBT community, people with autism, people in contact with the criminal justice system, particularly those in prisons, people in detention settings, including immigration detention settings, and specific occupation groups.

Recommendations for Custodial and Detention Settings

There are 10 main recommendations, and listed below are those points within each of those recommendations that I view as being more specific to custodial environments:

Suicide Prevention Partnerships

Set up a multi-agency partnership for suicide prevention in residential custodial and detention settings. This could consist of a core group and a wider network of representatives. Ensure the partnership has:

  • clear leadership
  • clear terms of reference, based on a shared understanding that suicide can be prevented
  • clear governance and accountability structures

…and then include representatives from the following in the partnership’s core group:

  • governors or directors in residential custodial and detention settings
  • healthcare staff in residential custodial and detention settings
  • staff in residential custodial and detention settings
  • pastoral support services
  • voluntary and other third-sector organisations
  • escort custody services
  • liaison and diversion services
  • emergency services
  • offender management and resettlement services
  • people with personal experience of a suicide attempt, suicidal thoughts and feelings, or a suicidal bereavement, to be selected according to local protocols

Suicide Prevention Strategies

Identify and manage risk factors and behaviours that make suicide more likely.

Consider collaborating with neighbouring residential custodial and detention organisations to deliver a single strategy.

Suicide Prevention Action Plans

Alongiside developing and implementing a plan for suicide prevention and for after a suspected suicide set out how to:

  • Work with the Prison and Probation Ombudsman and coroners to ensure recommendations from investigations and inquests are implemented
  • Implement recommendations from internal investigations of instances of self-harm
  • Assess suicide and self-harm prevention procedures (for example, HM Prison and Probation Service’s Assessment Care in Custody and Teamwork and Assessment care-planning system, and the Home Office’s Assessment Care in Detention and Teamwork case management systems)
  • Interpret and act on those findings
  • Ensure systems for identifying risk, information sharing and multidisciplinary working put the emphasis on ‘early days’ and transitions between estates or into the community
  • Monitor the impact of restricted regimes on suicide risk

Gathering and analysing suicide-related information

For residential custodial and detention settings, also collect data on:

  • sentencing or placement patterns
  • sentence type
  • offence
  • length of detention
  • transition periods (for example, ‘early days’ and transitions between estates or into the community)

Awareness raising by suicide prevention partnerships

For residential custodial and detention settings, also consider raising awareness of:

Reducing Access to Methods of Suicide

  • Provide safer cells
  • Reduce the opportunity by erecting physical barriers
  • providing information about how and where people can get help when they feel unable to cope
  • using CCTV or other surveillance to allow staff to monitor when someone may need help
  • increasing the number and visibility of staff, or times when staff are available

Training by Suicide Prevention Partnerships

Ensure training is available for:

  • those in contact with people or groups at high suicide risk
  • people working at locations where suicide is more likely
  • gatekeepers
  • people who provide peer support in residential custodial and detention settings
  • people leading suicide prevention partnerships
  • people supporting those bereaved by suicide

Supporting People Bereaved or Affected by a Suspected Suicide

Use rapid intelligence gathering and data from other sources, such as coroners to identify anyone who may be affected by a suspected suicide or may benefit from bereavement support. Those affected may include relatives, friends, classmates, colleagues, other prisoners or detainees, as well as first responders and other professionals who provided support.


  • providing support from trained peers who have been bereaved or affected by a suicide or suspected suicide
  • whether any adjustments are needed to working patterns or the regime in residential custodial and detention settings

Preventing and Reponding to Suicide Clusters

After a suspected suicide in residential custodial and detention settings, undertake a serious incident review as soon as possible in partnership with the health providers. Identify how:

  • to improve the suicide prevention action plan
  • to help identify emerging clusters
  • others have responded to clusters

Develop a coordinated approach to reduce the risk of additional suicides.

Develop a standard procedure for reducing – or ‘stepping down’ – responses to any suspected suicide cluster.

Provide ongoing support for those involved, including people directly bereaved or affected and those who are responding to the situation.

Reducing the potential harmful effects of media reporting of a suspected suicide

For residential custodial and detention settings, where a suspected suicide would be reported via the Ministry of Justice, ensure Ministry of Justice press officers follow good practice in suicide reporting.

Baseline Assessment Tool

Alongside these recommendations, NICE also provide a baseline assessment tool that can be used to evaluate whether practice is in line with the recommendations. This assessment tools can then also be used to plan activity to meet those recommendations.

Alongside those recommendations listed above, the tool can then be used to determine:

  • whether or not the recommendation is relevelant
  • current activity (evidenced accordingly)
  • whether or not the recommendation is met
  • actions needed to implement the recommendation
  • whether there are any associated risks with not implementing the recommendation
  • whether or not there is a cost or a saving
  • the deadline
  • the lead or person responsible


Preventing suicides in custodial environments isn’t something to be done on an annual basis. It is an ongoing commitment that is undertaken day in, day out. However, with the up and coming World Suicide Prevention Day on September 10th, I would encourage all those working within custodial environments to take full advantage on the resources on offer here.


Baseline Assessment Tool

Resource Impact Statement

NICE Guidelines – Preventing Suicide In Custodial Settings

Photo by Dan Meyers on Unsplash