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

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

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