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

A Summary of Safety in Custody Statistics July 2019: Deaths in Custody, Self-Harm and Assaults.

Deaths In Custody – 12 months to 30 June 2019

Overall, the number of deaths continues to fall but self-inflected deaths continue to rise.

309 deaths in prison custody, a decrease from 311 deaths the previous year. Of these, 86 deaths were self-inflicted, up from 81 the previous year.

There were 165 deaths due to natural causes which is a decrease from the 176 deaths in the previous year. 55 deaths are recorded as other, as 50 of those are awaiting further information.

Self-Harm – 12 months to 31 March 2019

Self-harm incidents reached a record high.

57,968 incidents reported which is a 24% increase from the previous 12 months. This is a rate of 699 incidents per 1000 prisoners.

By gender, this rate equates to 596 incidents per 1000 in the male estate (up 24%) and 2,828 per 1000 in the female estate (up 22%).

The number of individuals self-harming increased 12,539, representing a 6% increase on the previous year.

The number of self-harm incidents requiring hospital attendance increased by 5% to 3,261 in the same period. Of these 3,026 were in male prisons and 235 were in female prisons.

Assaults – 12 months to 31 March 2019

Assaults reach new a record high.

34,425 assaults reported which is an 11% increase on the previous year. Of these, 32,908 were in male prisons (up 11%) and 1,517 assaults were in female prisons (up 21%).

3,949 of these assaults were recorded as serious. A serious assault is one which falls into one or more of the following categories:

  • a sexual assault
  • requires detention in outside hospital as an in-patient
  • requires medical treatment for concussion or internal injuries

…or incurs any of the following injuries:

  • a fracture,
  • a scald or burn,
  • a stabbing,
  • crushing,
  • extensive or multiple bruising,
  • a black eye,
  • a broken nose,
  • a lost or broken tooth,
  • cuts requiring suturing,
  • bites,
  • temporary or permanent blindness.

There were 10,311 assaults on staff (up 15%). There were 24,541 prisoner-on-prisoner assaults, some of which may then involve those assaults on staff.

Full Report Here

A Summary of the MOJ Safety in Custody Quarterly Bulletin: An Update to December 2018

This bulletin was published on 25th April 2019, and provides a report on the Safety in Custody Statistics, England and Wales: Deaths in Prison Custody to March 2019 Assaults and Self-harm to December 2018. Also included in these figures are Immigration Removal Centres operated by HMPPS.

Deaths – 12 months ending March 2019

In the 12 months to March 2019, there were 317 deaths in prison custody, up 18 from the previous year. Of these, 87 deaths were self-inflicted, up 14 from the previous year, representing an increase on the previous 12 month period.

There were 3 apparent homicides, down from 5 incidents in the previous year. Homicides in prison custody remain relatively rare, accounting for around 1% of all deaths over the last ten years. There were 164 deaths due to natural causes, a decrease of 11% from 184 in the previous year. Natural-cause deaths were at a rate of 2.0 per 1,000 prisoners.

Self-Harm – 12 months to December 2018

Self-harm incidents reached a record high of 55,598 incidents in 2018, a 25% increase from 2017. The number of incidents between October and December decreased by 7% to 14,313 since the previous quarter.

The number of self-harm incidents requiring hospital attendance increased by 5% on the previous year to 3,214 while the proportion of incidents that required hospital attendance decreased by 1.1% to 5.8%.

The most common method for self-harm in prison was cutting/scratching, 54% females and 68% males self-harmed by cutting.

This was an increase of 27% for males and 12% for females in the most recent year. Hanging and self-strangulation both increased by over 35% for males since 2017. Hanging decreased by 7% for females in the previous year, although self-strangulation rose by 32%.

Consistently, prisoners in male establishments who are in prison between 31 days and 3 months were the most likely to self-harm.

Prisoners in both male and female establishments had the majority of self-harm incidents when they had been in custody between 31 days and 3 months, however for the first time in 2018, the majority of self-harm incidents occurred when prisoners had been in their current prison for over one year.

Assaults – 12 months to December 2018

Annual assault incidents reached a record high of 34,223 incidents in 2018, a 16% increase from 2017. Assaults in the October to December 2018 quarter decreased to 8,150, a decrease of 11% from the previous quarter, but a 5% increase on the same quarter of the previous year.

The proportion of assaults on staff increased to 30% of all incidents in 2018, an increase from 29% in 2017, and a steady increase from 20% between 2008 and 2011. The proportion of assaults on staff (38%) in female establishments in 2018 was higher than in male establishments (29%).

In the 12 months to December 2018, there were 3,918 serious assault incidents, up 2% from the previous year. Serious prisoner-on-prisoner assaults decreased by 1% since the previous year (to 2,987), and serious assaults on staff increased by 15% (to 995) in the same period. Serious assaults (by 4%), serious prisoner-on- prisoner assaults (by 5%), and serious assaults on staff decreased in the last quarter (by 4%).

There were 24,424 prisoner-on-prisoner assaults in 2018 (a rate of 293 per 1,000 prisoners), an increase of 15% from 2017, to a new record high.

Prisoner-on-prisoner assaults in male establishments rose by 15% to 23,538 incidents from the previous year, and assaults on staff in male establishments rose by 20% in the same period, to 9,665 incidents.

Female prisoner-on-prisoner assaults increased by 10% in 2018, to 886 incidents, and assaults on staff in female establishments increased 48% to 548 incidents. The proportion of assaults on staff (38%) in female establishments was higher than in male establishments (29%).

There were 10,213 assaults on staff in the 12 months to December 2018 (a rate of 123 per 1,000 prisoners), up 21% from the previous year. This is the highest level in the time series. The proportion of assaults on staff increased to 30% of all incidents in 2018, an increase from 29% in 2017, and a steady increase from 20% between 2008 and 2011.

Prisoners aged 30-39 had the highest proportion of assailants (25%), fighters (21%) and victims (28%) in 2018.

The number of assailants aged 30-39 had increased by 26% since the previous year, to 5,254 incidents. The number of fighters aged 30-39 increased by 7% to 2,966 and the number of victims aged 30-39 increased 12% to 4,040.

The number of incidents involving prisoners who had been in prison over one year has seen the biggest increase across all roles.

The number of assault incidents involving prisoners who had been in custody for 31 days to 3 months had smaller changes from the previous year for assailants (3% increase to 5,199 incidents), fighters (3% decrease to 3,642 incidents) and victims (1% decrease to 3,591 incidents), whereas prisoners who had been in prison over one year has increased for assailants (69% increase to 3,522), fighters (46% increase to 2,131) and victims (60% increase to 2,127).

Bulletin Summary.

  • Number of deaths have increased compared to the previous 12 month period.Self-harm incidents rose to 55,598 in 2018, a new record high, but decreased in the latest quarter.
  • Incidents requiring hospital attendance rose to a record high of 3,214 in 2018, although the proportion of incidents requiring hospital attendance has decreased.
  • Assault incidents increased to 34,223, a record high level in 2018, but decreased in the latest quarter.
  • The proportion of assaults on staff continue to rise.
  • Of the 34,223 assault incidents in 2018, 3,918 (11%) were serious.

Get the full bulletin here: