commits-suicide-in-jailStaff in prisons need to get better at spotting and using essential information about the risk of suicide among prisoners, said Prisons and Probation Ombudsman (PPO) Nigel Newcomen. Today he published a bulletin on the lessons that can be learned from investigations into the self-inflicted deaths of prisoners within the first month of custody.

This bulletin follows up a PPO review of self-inflicted deaths of prisoners in 2013/14 which found that a significant number of deaths occurred in the first month in prison. In a sample of 132 PPO investigations into self-inflicted deaths in prisons from April 2012 to March 2014, nearly a third of the deaths (40) occurred in the first 30 days and, of these, half died within the first week in prison. The most common theme arising from these investigations was the failure of staff to identify or act on information about factors known to increase prisoners’ risk of suicide or self-harm. This issue was also highlighted in a PPO thematic report about risk factors in 2014.

Among other findings, the report found that:

  • too often, staff in prison receptions make decisions based on their perceptions of a prisoner’s presentation and their assurances that they do not have any thoughts or intention of suicide or self-harm;
  • known risk factors which might increase the prisoner’s risk, such as a history of suicidal behaviour, or the circumstances of their offence, can be overlooked;
  • induction procedures are not always effective, meaning that newly arrived prisoners do not have all the information they need about the basics of prison life, such as how to make a telephone call;
  • recall to prison after a breach of licence is an inevitably distressing experience and a known risk factor for suicide and self-harm and when little information about their recall is provided to recalled prisoners, this can increase their distress even further; and
  • an inadequate consideration of mental health concerns, including failure to recognise symptoms of mental illness, failure to review or continue medication prescribed in the community and failure to make mental health assessment referrals, was common.

The lessons from the bulletin are that:

  • staff need to identify, record and act on all known risk factors during reception and first night;
  • all prisoners should receive an induction, regardless of location;
  • recently recalled prisoners can be especially vulnerable; and
  • continuity of mental health care and responsiveness to a prisoner’s mental health needs are essential.

Nigel Newcomen said:

“The early days and weeks of custody are often a difficult time for prisoners and a period of particular vulnerability for those at risk of suicide. The Prison Service has introduced reception, first night and induction processes to help identify and reduce this risk. Some prisoners have obvious factors, such as mental ill-health or a lack of experience of prison, that indicate that they are at heightened risk of suicide, but my investigations too often find that staff have failed to recognise or act on them – with potentially fatal consequences.”


  1. A copy of the report can be found on our website from 16 February 2016. Visit
  2. A copy of Learning from PPO Investigations: Self-inflicted deaths of prisoners – 2013/14 is available at
  3. A copy of Learning from PPO Investigations: Risk factors in self-inflicted deaths in prison is available at
  4. The PPO investigates deaths that occur in prison, immigration detention or among the residents of probation approved premises. The PPO also investigates complaints from prisoners, those on probation and those held in immigration removal centres.