NICE Guidance For Suicide Prevention in 2019

In September 2019, the National Institute for Health and Care Excellence (NICE) published new guidance for Suicide Prevention (Quality Standard 189).

This quality standard covers ways to reduce suicide and help people bereaved or affected by suicide. It describes high-quality care in priority areas for improvement by the outlining of 5 quality statements:

Statement 1 Multi-agency suicide prevention partnerships have a strategic suicide prevention group and clear governance and accountability structures.

Such a structure could be in the form of Safer Custody Teams made comprising all disciplines within each establishment that simply goes beyond representation from residential functions and mental health teams.

Quality measures would be evidenced through clear terms of reference and accurate minutes from meetings with the specific focus on planned actions and accountability.

Expected outcomes would be reductions in the rates of incidents of suicide and self-harm.

Statement 2 Multi-agency suicide prevention partnerships reduce access to methods of suicide based on local information.

Considerations:

  • Identify emerging trends in suicide methods and locations
  • Understand local characteristics that may influence the methods used
  • Determine when to take action to reduce access to the methods of suicide.

Reducing access to common methods of suicide and to places where suicide may be more likely to occur can be an effective way of preventing suicide, along with consideration of any measures that can be used to interrupt prisoner’s plans, enough to give them time to stop and think, or making it more difficult for them to put themselves in danger.

It’s not inconceivable that one of the positives of allowing smoking in prisons in England and Wales was the act of rolling a cigarette, that then allowed such an opportunity to stop and think. In the Smoke Free estate, it is doubtful that any e-cigarette or vape can fill the void of such a process. This isn’t the only example, but certainly one of the more obvious that springs to mind.

Statement 3 Multi-agency suicide prevention partnerships have a local media plan that identifies how they will encourage journalists and editors to follow best practice when reporting on suicide and suicidal behaviour.

Best practice when reporting on suicide and suicidal behaviour includes:

  • Using sensitive language that is not stigmatising or in any other way distressing to people who have been affected
  • Reducing speculative reporting (that often serves no other purpose than to attract more online “clicks” perhaps?)
  • Avoiding presenting detail on methods providing stories of hope and recovery including signposting to support.

Statement 4 Adults presenting with suicidal thoughts or plans discuss whether they would like their family, carers or friends to be involved in their care and are made aware of the limits of confidentiality.

The judgement may be that it is right to share critical information, which is what the Assessment, Care in Custody and Teamwork (ACCT) process permits. After all, families and friends would prefer to be involved, and be a part fo the support process rather than after the event when being informed that their loved one has completed suicide.

Statement 5 People bereaved or affected by a suspected suicide are given information and offered tailored support.

Support that is focused on the person’s individual needs. As well as professional support, it could include:

Improving Outcomes

The quality standard is expected to contribute to improvements in the following outcomes:

  • Quality of life for people bereaved or affected by suicide
  • Rate of self-harm
  • Hospital attendances and admissions for self-harm
  • Suicide rate.

Further Links/Resources

NICE – Suicide Prevention PDF

Support after a suicide: a guide to providing local services

National Suicide Prevention Alliance’s Support after a suicide: developing and delivering local bereavement support services.

Support After Suicide – Help Is At Hand

Photo by Jon Tyson on Unsplash

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.

Consider:

  • 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

Conclusion

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.

Links/Resources

Baseline Assessment Tool

Resource Impact Statement

NICE Guidelines – Preventing Suicide In Custodial Settings

Photo by Dan Meyers on Unsplash

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

Guidance: Suicide & Self-Harm Prevention In Prison

On 15th May 2019, the Government published guidance relating to the issues of suicide and self harm in prison.

The guidance acknowledges that the transition of going to prison affects people in different ways as they vary in their abilities to adapt and adjust in what may be a new environment. What should also be recognised is that fact that it also affects people in different ways when they are returning to what can may be considered be a familiar environment, which again can be viewed in either a positive or negative sense.

Either way, what is clear is that the risk factors for suicide are found more frequently among the prison population. Prisoners are a high risk population for suicide and self-harming behaviours. Those high risk times include:

  • early days and weeks (in local/remand prisons)
  • post transfer
  • post recall (in local/remand prisons)
  • post sentencing (in local/remand prisons)

Note the common theme above in the concentration of risk factors faced in local/remand prisons.

The guidance recognises that someone in crisis is likely to be:

  • actively engaged in self-harm or suicide attempts (although some may not be)
  • visibly agitated (although some may not be)
  • expressing current ideas and thoughts of suicide (although some may not be)

Identifying someone in crisis and reacting is different from identifying someone in need of support and intervening proactively. Many prisoners who complete suicide don’t present as ‘in crisis’. Sometimes they have limited risk factors beyond being male and incarcerated.

Theories of suicide suggest risk is heightened when people feel:

  • a lack of connectedness
  • burdensomeness
  • hopeless that things won’t change

Not everyone who self-harms intends on taking their own lives. Many incidents of self-harm are unrelated to suicidal ideation or intent, but there is a link. Over half of people who die by suicide have a history of self-harm.

Self-harm may occur at any stage of custody, when prisoners are trying to deal with difficult and complex emotions. This could be to punish themselves, express their distress or relieve unbearable tension or aggression. Sometimes the reason is a mixture of these. Self-harm can also be a cry for help, and should never be ignored or trivialised.

Steps To Take For Those Who Need Support.

Taking in account the probability of risk factors and the degree to which they may apply in the general sense, it could be suggested that each person be supported according to his or her own individual needs. Those step outlined within the guidance include:

  • Using the Assessment, Care in Custody and Teamwork (ACCT) case management system. ACCT is a prisoner-centred, multi-disciplinary process used for risk identification, care planning and support. Prison Service Instruction PSI 64/2011 requires that any prisoner identified as at risk of suicide or self-harm must be managed using ACCT – but for how long? When does a period of crisis end?
  • Forming positive relationships and fostering sense of connection to others. Prisoners at risk of suicide or self-harm can be supported through positive relationships. This can be staff/prisoner and prisoner/prisoner. This includes through peer mentoring schemes such as Listeners. Sustaining and improving prisoners’ relationships with their families and friends outside is important. It can help identify when someone is distressed and help them overcome it.
  • Supporting prisoners where appropriate through physical and mental health interventions, counselling or other support services.
  • Reducing a sense of burdensomeness. Helping prisoners engage in meaningful activities where they feel they are contributing, and enhancing hope for the future.
  • Information sharing and proactive multidisciplinary working. Communication between prison staff and partner agencies inside prison (like healthcare) and outside prison (like court and probation) must be robust. Including the prisoner themselves in all decisions and communications is important. Prisons should also ensure it is easy for prisoners’ family members to contact the prison to report concerns.
  • Training and support for staff. Staff should be empowered to make decisions based on the individual’s unique needs, and knowledge about best practice in addressing vulnerabilities and providing appropriate care. Ongoing training, up skilling and supervision will benefit staff and the individuals they support.
  • Staff showing that they care. Effective prison officers demonstrate good listening skills, recognise people’s humanity, and pass on hope and optimism.

Conclusion.

Suicide prevention initiatives are more effective when establishments adopt a whole prison approach. Taking steps to reduce suicide and self-harm reduction is everyone’s responsibility. Management visibility and leadership around suicide and self-harm prevention is extremely important.

Whilst the guidance is undoubtably helpful, identifying probable risk factors alone offers no reassurance for the prison officers and healthcare staff in keeping those within their charge, safe. If only it was that easy.

Read the full guidance here.

Photo by Ye Jinghan on Unsplash.


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:

https://www.gov.uk/government/statistics/safety-in-custody-quarterly-update-to-december-2018?utm_source=e92c3f9b-202f-4a56-9ab0-c3c73d03b8b8&utm_medium=email&utm_campaign=govuk-notifications&utm_content=immediate