Prison: Deaths, Assaults and Self-Harm – and the facts no amount of spin can conceal

 

By Mark Leech

 

 

Look, I get it.

When your back is against the wall and you’re up against it, when every single piece of evidence shows no matter what you do it stubbornly isn’t working, there is a real temptation to find virtue in anything.

But there is no virtue to be found in the latest safety in custody quarterly statistics, where every single one of the key indicators show a continuing annual rise in deaths, violence and self-harm.

Just look at the plain, stripped-of-spin, painful facts.

  • In the 12 months to March 2019, that’s just four weeks ago by the way, 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.
  • Self-harm incidents rose to 55,598 in 2018, a new record high.
  • Incidents requiring hospital attendance rose to a record high of 3,214 in 2018 and the number of self-harm incidents requiring hospital attendance increased by 5% on the previous year to 3,214.
  • Assault incidents increased to 34,223, a record high level in 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 show a 5% increase on the same quarter of the previous year.
  • The proportion of assaults on staff continue to rise. 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.
  • While serious prisoner-on-prisoner assaults decreased by just 1% since the previous year, serious assaults on staff rocketed by 15% (to 995) in the same period.

Now you tell me what has anyone who can read, talk and walk upright, got to applaud here?

When every single indicator across the quarter is at a higher figure than 12 months ago – often reaching yet more ‘new record highs’ – I find nothing to applaud at all.

But Prisons Minister Rory Stewart did.

Indeed despite the reality that every single annual indicator on deaths, assaults and self-harm showed increases, Rory made a video.

In it he managed to keep a straight face while celebrating the fact that, as he saw it, we have turned a corner, there is now light at the end of the tunnel, the signs of success are there he said, and we should all take comfort from the fact that he has it all under control.

No he doesn’t.

It’s one thing to mistake a swallow for the arrival of Summer, but it’s insane to look at these figures and say a single grain of sand means we’ve all arrived on a beach in Ibiza and it’s now Party Time.

No its not.

You can’t look at one quarter’s figures in this custodial world and make presumptions or try and extrapolate it into the future – especially when every single key annual indicator is still on the rise.

This is not a world where exact science works at all.

The prison population is constantly changing,  it’s fluid, it’s a world where there are people with mental illnesses, addictions, learning difficulties, impulsive behaviour issues, gang allegiances, where skilful manipulators and sophisticated fraudsters are at work.

It’s a place where there isn’t and never has been a one size fits all solution to anything.

It’s a world where when you think you’ve got something cracked the whole thing goes tits up proving you haven’t cracked it at all .

Exactly 25 years ago six Exceptional Risk Category A prisoners escaped from the ‘impregnable prison within a prison’ Special Secure Unit at Whitemoor prison, having managed to acquire a gun and ammunition they shot one prison officer and made it out of the unit over two walls and through a fence to short-lived freedom on the other side – the later Woodcock report revealed they’d also managed to smuggle into the SSU one pound of Semtex high explosive.

What seems calm and controlled one minute can blow up in your face the next – and then drop back down again as if nothing has happened just minutes later.

It’s a world where people aren’t afraid of consequences, being sent to prison doesn’t bother them – they’re already there – and they’ve largely spent a lifetime sticking two fingers up to authority and saying ‘fuck you’ whatever may then befall them.

You can take nothing for granted in this custodial world – and certainly not the fragile seeds of hope that even on the best view these figures do not represent.

I know,  I spent 14 years in prison,  during a prison career of riots and roof-top protests, segregation, ghost trains, and 62 different prisons until one day I arrived at Grendon Underwood where the healing process started, where for once I was treated with decency and respect and where my head was taken off and screwed back on the right way round and I haven’t looked back.

But in 61 other prisons it was ‘them and us’ – and consequences were irrelevant; which is why telling the public that the Government has doubled the sentence for assaults on prison officers may appear like progress, but in the real world of prison it’s utterly meaningless – neither prevention nor cure work here, only reasoning succeeds in the end.

I don’t doubt at all that Rory Stewart and David Gauke have the best of intentions but they are political animals, they have a concave view of the world in which they tell lies for a living – no disrespect, it’s just what politicians do – they call it putting a spin on things but to many people it’s just lying.

Yes, the 10 Prisons Project has had some success, I don’t deny that, it was inevitable and it would be strange if the investment in those prisons didn’t see cleaner wings, brighter landings, fresher environments and progress – but there are another 108 prisons where that simply isn’t the case; in fact there are another 108 prisons where things are going from bad to worse and no amount of spin or fresh paint can conceal it.

Don’t take my word for it, just go to the IMB web site and just read the latest annual reports just published.

IMB at HMP Durham: ….The prison has seen large increases in the use of force, assaults, death in custody and illegal use of drugs

IMB at HMP Haverigg …. widespread use of Psychoactive Substances (PS), not only with respect to those addicted to its use but on the general prison population, staff and also on the overall regime.

IMB at HMP Channings Wood …. decline in both the safety and well-being of the prisoners and in the physical condition of their surroundings with a significant increase in the use of the drug Spice and a serious deterioration in the state of the men’s living blocks.

IMB at HMP Hewell say the prison isn’t even fit for the 21st Century – 20 years after we entered it, widespread use of illicit drugs and mobile phones….

And so it goes on.

A splash of spin and a coat of paint can’t conceal reality – Queen Victoria thought the world smelt of fresh paint because, wherever she went, ten feet in front of her was a man with a paint brush; but had she turned the corner, had she gone off-tour, she would have collided with a reality where filth, stench and danger were obvious to anyone who cared to look.

Well, I care to look.

I want to be optimistic, I want to see progress, but equally I refuse to be deceived and distracted by political spin from the reality of a prison world that is, on the statistical facts, one where in terms of violence, death and self-harm it is getting worse not better.

When we’ve had 12 months not 12 weeks (and we haven’t had a single week across all four key indicators yet let’s not forget) of falling figures on deaths, self-harm and assaults in our prisons, when anecdotal evidence matches the figures and confirms that control has been regained and retained then – and not until then – we can say that progress has genuinely been made; rather than just a second-rate video that frankly was as risible to watch as it was as laughable to listen to.

Mark Leech FRSA is the Editor of The Prisons Handbook for England and Wales. @prisonsorguk

HMP Durham: Must Address Violence, Drugs and Deaths says Inspectors

HMP Durham, a heavily overcrowded prison, was found by inspectors to have significant problems with drugs and violence and worryingly high levels of self-harm and self-inflicted and drug-related deaths.

Durham became a reception prison in 2017. Around 70% of the 900 men in the jail were either on remand or subject to recall and over 70% had been in Durham for less than three months. On average, 118 new prisoners arrived each week. Significant numbers of prisoners said they arrived at the jail feeling depressed or suicidal. Self-harm was very high.

Peter Clarke, HM Chief Inspector of Prisons, said: “Our overriding concern was around the lack of safety. Since the last inspection in October 2016, there had been seven self-inflicted deaths, and it was disappointing to see that the response to recommendations from the Prisons and Probation Ombudsman (which investigates deaths) had not been addressed with sufficient vigour or urgency.

“There had also been a further five deaths in the space of eight months where it was suspected that illicit drugs might have played a role.” Drugs were readily available in the jail and nearly two-thirds of prisoners said it was easy to get drugs; 30% said they had acquired a drug habit since coming into the prison. “These were very high figures”, Mr Clarke said, though the prison had developed a strategy to address the drugs problem.

The leadership, Mr Clarke added, was “immensely frustrated by the fact that they had no modern technology available to them to help them in their efforts to stem the flow of drugs into the prison. We were told that they had been promised some modern scanning equipment but that it had been diverted to another prison.” The scale of the drugs problem and related violence meant that technological support was urgently needed.

Since the last inspection at Durham in 2016, violence had doubled and the use of force by staff had increased threefold, though some of the increase in force may have been due to new staff who were not yet confident in using de-escalation techniques. Governance of the use of force had improved.

Mr Clarke added: “There were some very early signs that the level of violence was beginning to decline, but it was too early to be demonstrable as a sustainable trend.”

Alongside these concerns, inspectors noted “many positive things happening at the prison.” These included the introduction of in-cell phones and electronic kiosks on the wings for prisoners to make applications, which had “undoubtedly been beneficial”. The disruption caused by prisoners needing to be taken to court had been reduced by the extensive use of video links.

A new and more predictable daily regime had recently been introduced, increasing access for men to amenities such as showers and laundry on the wings. “For a prison of this type, the time out of cell enjoyed by prisoners was reasonable and it was quite apparent that, despite its age, the prison was basically clean and decent,” Mr Clarke said. It was also good that the leadership saw new staff as an opportunity to make improvements, not an inexperienced liability.

Overall, Mr Clarke said:

“There was no doubt that there was an extent to which HMP Durham was still going through the process of defining, refining and responding to its role as a reception prison. The very large throughput of prisoners gave rise to the risk that taking them through the necessary processes could predominate over identifying individual needs and ensuring favourable outcomes. However, the prison was aware of this risk. The most pressing needs are to get to grips with the violence of all kinds, make the prison safer and reduce the flow of drugs. Only then will the benefits flow from the many creditable initiatives that are being implemented.”

Mark Leech, Editor of The Prisons Handbook for England and Wales said:

“Apart from security, safety must be the primary function of any prison but the number of deaths at Durham, and particularly the failure to implement the recommendations of the Prisons and Probation Ombudsman designed to reduce deaths in custody, is deeply worrying.

“Only yesterday I wrote an open Letter about this issue to the Ombudsman, and this report reinforces the point that prisons must have the resources to implement PPO recommendations otherwise what is the use of them in the first place?”

Prisons minister Rory Stewart said: “We are determined to install full airport-style security with the right dogs, technology, scanners and search teams to detect drugs.

“We will install the technology in Durham and we will be rolling it out across our local prisons. Tackling drugs is vital for reducing violence.”

Deaths in Custody: The Noose Around The Ombudsman’s Neck

pdf version

open letter from Mark Leech The Editor of The Prisons Handbook for England and Wales, to The Prisons and Probation Ombudsman

 

Dear Sue,

Recommendation Recommendation Recommendation Recommendation Recommendation Recommendation Recommendation Recommendation Recommendation Recommendation.

Did you bother reading each of those words – or notice I had inserted a number in one of them?

Actually, I didn’t, but you went back anyway and read them again; right?

Unfortunately, that isn’t what happens to the ‘Recommendations’ you make in your Fatal Incident Reports into deaths in custody; people don’t go back and read them again.

When you set out your ‘Recommendations’ designed to learn lessons and reduce deaths in custody, no one takes a blind bit of notice of them – and, what’s worse, your Office ignores the fact they’re ignored too.

Tragically you’re not alone in looking the other way. Independent Monitoring Boards (IMBs) in whose prisons these deaths take place, and to whom monitoring the implementation of these Recommendations should be a priority, ignore them too. Year after year, they simply airbrush them out of their Annual Reports as if they have never been made; I will return to this shortly.

Every single Prisons Ombudsman that’s gone before you in the last 25 years at least had the excuse that they’ve never unlocked a prison cell door and found a prisoner swinging dead with a noose around their neck; but as a former Prison Governor you don’t have the luxury of that excuse. You know exactly what it’s like: the shock, horror, frantic attempts at resuscitation, and the wave of utter devastation that then descends on the whole prison afterwards.

Yet, despite that personal experience deaths in custody keep happening and frequently too; as I write this we are six weeks into 2019 and already 20 people have died in our prisons – 17 of whom have seemingly taken their own lives, and eight definitely have.

Your Office still keeps investigating these deaths, still keeps writing their reports, still keeps making recommendations, and still does absolutely nothing when, time after time, those recommendations are ignored – lamentably this week you’ve done it again.

John Delahaye was 46 years old when he was found dead in his cell at Birmingham Prison on 5 March 2018; let me remind you of the catalogue of errors that lead up to it.

Ten weeks before his death Mr Delahaye was taken from Birmingham prison and admitted to hospital almost certainly having taken an insulin overdose; he returned to prison 24 hours later.

In your report into his death published this week, you write:

“When Mr Delahaye returned to Birmingham on 1 January following this overdose, there was no handover between hospital and prison healthcare staff and prison healthcare staff did not know he had returned to prison until the next day. 

I am also concerned that suicide and self-harm monitoring procedures (known as ACCT) were not started until the day after he had returned to prison. In addition, I have concerns about the way the ACCT procedures were managed when they were started. Staff did not effectively investigate why Mr Delahaye had taken the overdose and healthcare staff were not involved. The ACCT was closed prematurely two weeks later, with little having been done to identify or mitigate Mr Delahaye’s risk to himself. This was compounded by the fact that Mr Delahaye was discharged from mental health services after just one appointment.

I am concerned to be repeating recommendations to Birmingham about suicide and self-harm prevention procedures. [emphasis added]

“It is very difficult to understand why Mr Delahaye was allowed to have his insulin back in his possession less than a month after his overdose. I am concerned that NHS guidelines were not followed when this decision was made. 

“I also have serious concerns about the way staff at Birmingham conducted roll checks and unlocks. When Mr Delahaye was found on the morning of 5 March, he had clearly been dead for some time and it seems possible that no member of staff had seen him for more than 13 hours.

“This needs to be rectified urgently. 

“Staff also failed to use an emergency code when they found Mr Delahaye unresponsive. Although this did not affect the outcome for Mr Delahaye, it could make a critical difference in other cases.” 

Now, take a moment to look too at the Birmingham Prison IMB Annual Report published just 10 weeks ago and covering the period in which Mr Delahaye died in the prison. Neither his name, the circumstances of his death, nor the fact that your repeated recommendations had been ignored, are ever mentioned; not even once – they’re airbrushed out of existence; small wonder then why so many consider the IMB as completely and utterly useless?

I would remind you that your Office is not investigating the loss of someone’s property here, but the loss of someone’s life; yet it consistently fails to understand this vital distinction.

I accept the fact you are new to this role, and while there are those who say that as a former Prison Governor you are not the right person to be holding this critical Independent Office, I’m not yet one of them. I think your experience as a Governor means you know where to look, what questions to ask, what answers to demand and having opened cell doors and cut dead people down you know exactly how important all this really is.

The question is: when will we see action from your Office and not just words that everyone, including IMBs, totally ignore?

Yours sincerely,

Mark Leech

Editor: The Prisons Handbook for England and Wales

@prisonsorguk

Recent PPO Fatal Incident (Death in Custody) Reports

The Prisons & Probation Ombudsman has published the following self-inflicted death in custody reports in the last seven days.

Mr Robert McLoughlin was found hanging in his cell at HMP Leeds on 20 February, and died in hospital five days later, on 25 February, never having regained consciousness. He was 32 years old. I offer my condolences to Mr McLoughlin’s family and friends. Although Mr McLoughlin was subject to Prison Service suicide and self-harm monitoring procedures at the time of his death, I am concerned that the prison did not properly address or mitigate his risk factors. Had the suicide and self-harm monitoring procedures operated more effectively, staff might have made more informed decisions about how best to support him. I am concerned that I have repeatedly criticised the management of suicide and self-harm at Leeds and note that the Chief Inspector of Prisons has raised similar concerns. It is essential that the lessons from Mr McLoughlin’s tragic death are quickly and effectively acted upon.

Full report.

Mr Mark Doyle was found hanged in his cell on 22 March 2017 at HMP Pentonville and died in hospital six days later. Mr Doyle was 45 years old. We offer our condolences to Mr Doyle’s family and friends. The investigation into Mr Doyle’s death found deficiencies in the management of the ACCT process, specifically in assessing risk and delivering appropriate levels of observations. Control room staff did not immediately call an ambulance when the emergency was raised. Faulty cell bells were not reported and were not checked daily as required. We are troubled that mental health staff did not consider all available information in considering Mr Doyle’s referral. There have been six self-inflicted deaths at Pentonville since 2016. We are very concerned to repeat in this report recommendations that have been made in previous investigations into deaths at Pentonville. Given these concerns, the Prisons Group Director for London and Thames Valley should commission a review on the operation and management of the ACCT process at HMP Pentonville. As part of this review, he should, in particular, assure himself that HMP Pentonville has effectively implemented all PPO recommendations following self-inflicted deaths at the prison in the last five years and provide a report to me outlining progress within 3 months of receiving this report.

Full report.

Mr Jack Denison died of sepsis and pneumonia at hospital on 31 May 2016, while a prisoner at HMP Wymott. He was 86 years old. I offer my condolences to Mr Denison’s family and friends. Mr Denison was a frail man with several health conditions which healthcare staff managed well. I am satisfied that his care in prison was equivalent to that he could have expected to receive in the community and healthcare staff could not have prevented his death. Although it did not affect the cause of death, I am concerned that poor communication between HMP Garth and Wymott resulted in Mr Denison missing vital hospital appointments. There was no medical input to the security risk assessment when Mr Denison was taken to hospital and managers gave insufficient consideration to the impact of his health on his level of risk. It is also a concern that Mr Denison’s next of kin details were not updated when he arrived at Wymott.

Full report.

Mr Gary Lines was found hanged in his cell at HMP Northumberland on 18 September 2015. He was 44 years old. I offer my condolences to Mr Lines’ family and friends. Prison staff had begun suicide and self-harm prevention procedures when Mr Lines harmed himself on 13 September, but case reviews were not multidisciplinary and healthcare staff were not involved. No one checked Mr Lines’ community prescription from the time he arrived in prison on 8 August and he was not prescribed antidepressants, which he said he needed to help drive off suicidal thoughts, until the day before he died. While I consider it would have been difficult to predict that Mr Lines was at high and imminent risk of suicide, I am concerned that a lack of effective information sharing and consideration of his risk factors led to his risk being underestimated and a low level of observations. On the morning he was found hanged, I am not satisfied that staff checked Mr Lines’ wellbeing effectively.

Full report.

Mr John Duffey was found hanged in his cell at HMP Liverpool on 16 July 2016. He was 44 years old. I offer my condolences to Mr Duffey’s family and friends. Mr Duffey was a military veteran with a diagnosis of post-traumatic stress disorder and depression. He had a long history of illicit drug use and alcohol abuse. The investigation found deficiencies in the operation of suicide and self-harm prevention procedures at the prison. I am concerned that this is not the first time that I have found suicide and self-harm prevention procedures to be inadequate at Liverpool. However, I do not consider that staff at Liverpool could have predicted that Mr Duffey intended to take his own life when he did and, therefore, could not have prevented his actions. Fellow prisoners said that Mr Duffey was a regular user of ‘Spice’, a new psychoactive substance, that he was being bullied and was in debt for drugs, but the investigation found no evidence to corroborate these claims. Nevertheless, I note the ease with which Mr Duffey appeared to have been able to acquire illicit drugs at Liverpool and the prison needs to increase its efforts to combat the risks posed to prison safety particularly by new psychoactive substances.

Full report.

Did prisoners take their lives because they could no longer face violent, drug-ridden jail? – Chief Inspector

Peter Clarke, HM Chief Inspector of Prisons, has asked whether prisoners in HMP & YOI Nottingham took their own lives because they could no longer face life in the violent, drug-ridden jail.

In one of the most disturbing inspection reports in recent years, Mr Clarke posed the question in relation to eight apparent self-inflicted deaths between inspections in February 2016 and January 2018, part of an “appalling and tragic” picture of suicide and self-harm in Nottingham.

The formal cause of death in those cases will be decided by inquests but Mr Clarke said: “For too long prisoners have been held in a dangerous, disrespectful, drug-ridden jail. My fear, which may prove to be unfounded, is that some could face it no longer and took their own lives.”

HM Inspectorate of Prisons (HMIP) inspected the East Midlands jail in 2014. That was, like the vast majority of inspections, an unannounced visit. Safety then was assessed as poor, the lowest grade. The following inspections in 2016 and 2018 were, unusually, announced in advance. Despite this, safety was yet again found to have remained at a poor assessment. This spurred Mr Clarke to invoke the first ever use of a new ‘Urgent Notification’ protocol, which requires the Secretary of State for Justice, publicly, to take personal responsibility for improving a jail with significant problems. This centred on a “dramatic decline” at Nottingham and a “persistent and fundamental lack of safety”.

Mr Clarke said: “This prison will not become fit for purpose until it is made safe. It was clear from our evidence that many prisoners at Nottingham did not feel safe.” Inspectors identified disturbing findings:

  • Forty per cent of prisoners in the inspection survey said they felt unsafe on their first night in the jail; 67% that they had felt unsafe at some point during their stay; and 35% that they felt unsafe at the time of the inspection. Well over half reported bullying or victimisation.
  • Reported violence had not reduced since 2016, with 103 assaults against staff in the six months before the inspection. In the same period, there were nearly 200 incidents of prisoners climbing on the safety netting between landings. Inspectors said the overall level of disorder “contributed to a tense atmosphere at the prison.”
  • Well over half of prisoners said drugs were easily available and 15% had acquired a drug problem since entering the prison.
  • Use of force by staff had increased considerably since 2016 with nearly 500 incidents in the six-month period prior to the inspection, yet governance and supervision of such interventions were weak.
  • Just under half of prisoners had mental health needs and a “very high” 25% – 116 prisoners – were under psychiatric care. A quarter of prisoners said they felt suicidal on arrival in Nottingham.
  • Levels of self-harm were far too high, with 344 occurrences recorded in the six months up to the inspection.

Not surprisingly, Mr Clarke said, “in a prison which could be defined by the prevalence of drugs and violence, the level of suicide and self-harm was both tragic and appalling. Since our previous visit, eight prisoners had taken their own lives, with four of these tragedies occurring over a four-week period during the autumn of 2017.  Just a few short weeks after this inspection, a ninth prisoner was believed to have taken his own life.

“We were concerned that some repeated criticisms related to these deaths made by the Prisons and Probation Ombudsman (PPO) (which investigates prison deaths) had not been adequately addressed. For example, cell call bells were still not being answered promptly.”

Mr Clarke added: “We do not claim that the prison had been completely inactive in the face of these challenges. A new violence reduction strategy had been prepared in late 2017… However, this work was fitful and had yet to have an impact.” The prison also had a drug supply reduction policy, though it was not embedded and was not effective.

Inspectors also acknowledged an increase in staff numbers in recent months, though they noted that “too many staff were passive, lacked confidence in dealing with issues or in confronting poor behaviour, and prisoners did not yet see them as reliable or able to deal with the many daily frustrations they faced.”

Health care was reasonably good, and there were plans to improve mental health provision. Daily routines were more predictable and more activities were available for prisoners. There were also “some creditable efforts to prepare men for release”.

The prison governor assured inspectors they had understood the scale of the problems. Mr Clarke said: “I am hopeful that the Urgent Notification will galvanise Her Majesty’s Prison and Probation Service (HMPPS) to provide the support the prison needs to make it an acceptable environment in which to hold prisoners. If this is to happen, there will need to be levels of supervision, support and accountability that have been absent in the past.” The HMPPS action plan drawn in response to the Urgent Notification in January 2018 promised “much that is welcome in terms of review, audit and analysis. However, this must all be translated into tangible action to improve the day-to-day experience, safety and well-being of prisoners. Unless this happens, I fear that progress will be neither substantial nor sustainable.”

Overall, Mr Clarke said:

“This was yet again a very poor inspection at Nottingham that left me with no alternative but to bring matters directly to the attention of the Secretary of State by invoking the urgent notification procedure. The record of failure, as set out in this report, cannot be allowed to continue.”

Michael Spurr, Chief Executive of Her Majesty’s Prison & Probation Service, said:

“We published an immediate response to the Chief Inspector’s concerns on 14 February and have today published a comprehensive plan setting out the practical actions we are taking to improve conditions at HMP Nottingham. Drug testing has been increased, specialist staff are working with vulnerable prisoners and safety is the absolute priority for the Governor and staff every day. We have strengthened management arrangements, are providing external support and will monitor progress closely over the coming months.”

A copy of the full report, published on 16 May 2018, can be found on the HM Inspectorate of Prisons website at: www.justiceinspectorates.gov.uk/hmiprisons

Prison Deaths From New Psychoactive Substances Rises To 79 Says Ombudsman

spice

The number of prisoner deaths in which the use of new psychoactive substances (NPS) may have played a part has now risen to at least 79, said Prisons and Probation Ombudsman (PPO) Nigel Newcomen. Tonight (11/7/2017) he addressed the All-Party Parliamentary Group on Penal Affairs at the House of Lords.

Looking back at his six-year tenure, and discussing the rise in self-inflicted deaths in prisons, Mr Newcomen said the prison system was yet to emerge from a crisis. He discussed major themes that have emerged from his investigations and studies into deaths in custody that need to be acted upon, and mentioned the problem of mental ill-health among prisoners, which needs to be better recognised by staff and, if recognised, better managed.

 

Nigel Newcomen said:

“As well as mental ill-health, another contributory factor to the increase in suicide in prison is the epidemic of new psychoactive substances. My researchers have now identified 79 deaths between June 2013 and September 2016 where the deceased was known or strongly suspected to have taken NPS before death or where their NPS use was a key issue during their time in prison. Of these investigations, 56 were self-inflicted deaths.

In the past, Mr Newcomen has highlighted the four types of risk from NPS:

  • a risk to physical health – NPS use may hasten the effects of underlying health concerns;
  • a risk to mental health, with extreme and unpredictable behaviour and psychotic episodes, sometimes linked to suicide and self-harm;
  • behavioural problems, where the NPS user has presented violent or aggressive behaviour, which is often uncharacteristic for that prisoner; and
  • the risk of debt or bullying, as the use of NPS often results in prisoners getting into debt with prison drug dealers.

Nigel Newcomen said:

“Establishing direct causal links between NPS and the death is not easy, but my investigations identified a number of cases where my clinical reviewers considered that NPS led to psychotic episodes which resulted in self-harm. In other cases, NPS led to bullying and debt of the vulnerable, also resulting in self-harm.

“NPS is a scourge in prison, which I have described as a “game-changer” for prison safety. Reducing both their supply and demand for them is essential.

“But neither mental ill-health, nor the availability of NPS wholly explain the rise in suicides in prison. Every case is an individual tragedy with numerous triggers. And, in such complex circumstances, the safety net of effective suicide prevention procedures is essential. Unfortunately, too often my investigations identify repeated failings in prison suicide prevention procedures.”

Mark Leech editor of The Prisons Handbook said: “This further rise in prison deaths attributable to NPS is deeply concerning, it shows that despite a range of measures introduced by HMPPS, and a Thematic Review by the Chief Inspector of Prisons in December 2015, these dangerous drugs continue to cause deaths inside our prisons.

“Research shows that synthetic cannabinoids, usually known as Spice or Black Mamba, form the only category of illicit drugs whose use by prisoners is higher in prisons than in the community, 10% compared to 6%, and there is no easy answer to it – many of those who take NPS say they do so for reasons of boredom one solution therefore is to resource the Prison Service to deliver the active purposeful regimes that have been steadily stripped away since 2010.”

The Prisons Handbook: Further reading and research on NPS can be found at the following links

■ NPS in Prisons – a Toolkit for Staff: http://www.nta.nhs.uk/uploads/9011-phe-nps-toolkit-update-final.pdf

■ Drug Misuse: Findings from the 2015/16 Crime Survey for England and Wales https://www.gov.uk/government/statistics/drug-misusefindings-from-the-2015-to-2016-csew

■ Changing patterns of substance misuse in adult prisons and service responses. A thematic review by HM Inspectorate of Prisons https://www.justiceinspectorates.gov.uk/hmiprisons/ wp-content/uploads/sites/4/2015/12/Substance-misuseweb-2015.pdf

■ Adult substance misuse statistics from the National Drug Treatment Monitoring System (NDTMS)1st April 2015 to 31st March 2016 http://www.nta.nhs.uk/uploads/adult-statistics-from-thenational-drug-treatment-monitoring-system-2015-2016[0].pdf

■ HM Chief Inspector of Prisons for England and Wales Annual Report 2014–15 https://www.justiceinspectorates.gov.uk/hmiprisons/wpcontent/uploads/sites/4/2015/07/HMIP-AR_2014-15_TSO_ Final1.pdf

■ HM Chief Inspector of Prisons for England and Wales Annual Report 2015–16 https://www.justiceinspectorates.gov.uk/hmiprisons/wpcontent/uploads/sites/4/2016/07/HMIP-AR_2015-16_web-1. pdf

■ Spice: the bird killer (User Voice May 2016) http://www.uservoice.org/wp-content/uploads/2016/05/ User-Voice-Spice-The-Bird-Killer-Report-Low-Res.pdf

■ Project NEPTUNE guidance, 2015 www.neptune-clinical-guidance.co.uk/wp-content/ uploads/2015/03/NEPTUNE-Guidance-March-2015.pdf

■ Harms of Synthetic Cannabinoid Receptor Agonists (SCRAs) and Their Management. Novel Psychoactive Treatment UK Network NEPTUNE http://neptune-clinical-guidance.co.uk/wp-content/ uploads/2016/07/Synthetic-Cannabinoid-ReceptorAgonists.pdf

■ Ministry of Justice press release, 25 January 2015 www.gov.uk/government/news/new-crackdown-ondangerous-legal-highs-in-prison

■ Centre for Social Justice, ‘Drugs in prison’, 2015 http://www.centreforsocialjustice.org.uk/library/drugs-inprison

■ EMCDDA, European Drug Report 2015: ‘Trends and developments’, June 2015 www.emcdda.europa.eu/publications/edr/trendsdevelopments/2015

■ Drugscope, ‘Not for human consumption: an updated and amended status report on new psychoactive substances and ‘club drugs’ in the UK’,2015 http://www.re-solv.org/wp-content/uploads/2015/06/Notfor-human-consumption.pdf

■ PHE, ‘New psychoactive substances. A toolkit for substance misuse commissioners’, 2014 www.nta.nhs.uk/uploads/nps-a-toolkit-for-substancemisuse-commissioners.pdf

■ Home Office, ‘Annual report on the Home Office Forensic Early Warning System (FEWS). A system to identify new psychoactive substances (NPS) in the UK’, September 2015 https://www.gov.uk/government/uploads/system/uploads/ attachment_data/file/461333/1280_EL_FEWS_Annual_ Report_2015_WEB.pdf

■ Global Drug Survey 2016 https://www.globaldrugsurvey.com/past-findings/theglobal-drug-survey-2016-findings/

A copy of the speech can be found on the PPO’s web site from 14 July 2017. Visit www.ppo.gov.uk.

Six prison homicides in one year reflect unacceptable level of prison violence, says Ombudsman

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Homicides in prison are still rare but the number has increased, vividly illustrating the unacceptable level of violence in prisons in England and Wales, said Nigel Newcomen, Prisons and Probation Ombudsman (PPO). Today he published a bulletin on lessons that can be learned from his investigations.

The PPO investigates all deaths in custody and his remit is to examine the circumstances surrounding the death and establish whether anything can be done to help prevent similar tragedies in the future. In December 2013 he published a bulletin which looked at 16 prison homicides investigated from 2003-4 to 2012-13, an average of 1.6 per year. The 2013 bulletin identified a number of concerns, in particular the need to improve the management of risk that vulnerable prisoners pose to one another. It led to operational changes in high security prisons.

In the three years that followed, from 2013-14 to 2015-16, another 13 prisoners were killed by another prisoner or prisoners (an average of 4.3 homicides per year). This bulletin considers the learning from six of those 13 homicides where investigations have been completed, and another two from the beginning of 2013.

The bulletin highlights the need for:

  • prisons to have a coordinated approach to identifying indicators and risks of bullying and violent behaviour, including the impact of new psychoactive substances and associated debt, and taking allegations of intimidation seriously;
  • prisons to have an effective security and cell-searching strategy, enabling weapons to be found and removed;
  • concerns about potentially vulnerable prisoners to be properly recorded and action taken to ensure prisoners are located in a place of safety; and
  • the police to be notified without delay when a prisoner appears to have been seriously assaulted, evidence preserved and all prisoners involved in an incident to be held separately until police arrive.

 

Nigel Newcomen said:

“The killing of one prisoner by another in a supposedly secure prison environment is particularly shocking, and it is essential to seek out any lessons that might prevent these chilling occurrences in future.

“The cases we studied had little in common beyond their tragic outcome. Nevertheless, what is clear is that the increased number of homicides is emblematic of the wholly unacceptable level of violence in our prisons.

“The bulletin does identify a number of areas of learning: the need to better manage violence and debt in prison, not least that associated with the current epidemic of new psychoactive substances; the need for rigorous cell searching to minimise the availability of weapons; the need for careful management of prisoners known to be at risk from others and the need to ensure prisons know how to respond when they have an apparent homicide.”

Mark Leech, editor of The Prisons Handbook for England and Wales and Converse, said:

“The rising tide of violence in our prisons is what happens when staffing levels are cut beyond safe levels, when budgets are slashed that allow already attenuated regimes to deteriorate further and when the Prison Service has yet to get to grips with the impact of high levels of New Psychotic Substances which are increasingly widely available across the entire prison estate.

“When you strip away the political rhetoric, the promises of more staff, the assertions that the Prison Service is doing all it can, the simple fact is that you cannot run a modern, safe, prison service on tuppence ha’penny – that’s the shockingly simple truth of the matter at the end of the day.”

A copy of the bulletin is here.

Better Safety Must Underpin Prison Reform Says Ombudsman As Suicides, Homicides and Deaths From Natural Causes Reach Record Levels

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The past year saw a 34% rise in prison suicides, more deaths from natural causes and the highest number of homicides in prison for many years, said Prisons and Probation Ombudsman Nigel Newcomen. Today he published his fifth and final annual report and warned that prison reform could stall without a focus on safety and fairness.

The Prisons and Probation Ombudsman (PPO) independently investigates the circumstances of each death in custody and identifies lessons that need to be learned to improve safety. In 2015-16:

  • PPO investigations were started into 304 deaths, 21% more than the year before;
  • the PPO began 10% more investigations into deaths from natural causes (172 deaths), largely as a consequence of rising numbers of older prisoners (the average age of those who died of natural causes was 61);
  • investigations were started into 103 self-inflicted deaths, the highest number in a single year since the Ombudsman began investigating deaths in custody, and a 34% increase from 2014-15;
  • there were six apparent homicides, compared with four the previous year; and
  • a further 11 deaths were classified as ‘other non-natural’ (usually drug related) and 12 await classification.

Nigel Newcomen said:

“Over the past year, deaths in custody have risen sharply, with a shocking 34% rise in self-inflicted deaths, steadily rising numbers of deaths from natural causes and the highest number of homicides since my office was established.

“Together with rising levels of violence and disorder, these figures are evidence of the urgent need to improve safety and fairness in prison. Progress in prison reform will be limited unless there is a basic underpinning of safety and fairness on which to build.

“Unfortunately, I have been saying many of the same things for much of my time in office. While resources and staffing in prisons are undeniably stretched, it is disappointing how often – after invariably accepting my recommendations – prisons struggle to sustain the improvement I call for. Ensuring real and lasting improvement in safety and fairness needs to be a focus on the new prison reform agenda.”

On suicides, he said:

“It is deeply depressing that suicides in custody have again risen sharply but it is not easy to explain this rising toll of despair. Each death is the tragic culmination of an individual crisis. Some major themes do emerge from my investigations, for example the pervasiveness of mental ill-health and the destructive impact of an epidemic of new psychoactive substances, but no simple explanation suffices.

“In such a complex context, effective and thoughtful efforts at prevention by prison staff are vital. Unfortunately, too often my investigations identify repeated procedural failings. For example, I have frequently identified gaps in the assessment of risk of suicide and self-harm and poor monitoring of those identified as being at risk. More can and should be done to improve suicide and self-harm prevention in prison”

The other principal part of the PPO’s remit is the independent investigation of complaints. In 2015-16:

  • the total number of new complaints received was 4,781, a 4% decrease on the previous year;
  • 2,357 investigations were started, just 23 cases fewer than the year before;
  • overall, 2,290 investigations were completed, a 6% increase on 2014-15;
  • in 40% of the investigations, the PPO found in favour of the complainant, compared with 39% the previous year; and
  • the largest category of complaints was about lost, damaged and confiscated property.

Nigel Newcomen said:

“The ability to complain effectively is integral to a legitimate and civilised prison system. In each of my annual reports, I have listed the raft of challenges facing the prison system, which go some way to explaining the sustained levels of complaints reaching my office. These strains in the system may also be reflected in the increasing proportion of complaints from prisoners that I uphold because prisons got things wrong, often in contravention of their own national policies.

“Avoiding mistakes and ensuring basic fairness will also need to be at the heart of any prison reforms. Greater autonomy for governors must be balanced by clear statements of minimum entitlements for prisoners.”

The recommendations made as a result of PPO investigations are key to making improvements in safety and fairness in custody. The past year also saw the publication of a range of learning lessons publications which look across individual investigations to identify broader themes. In 2015-16, bulletins looked at how to avoid the increase of suicides by prisoners in segregation units, how to address deaths associated with new psychoactive substances and how to manage those at risk of suicide in the early days of custody. A thematic study looked at the issue of mental ill health, and a bulletin looked at how legal mail should be dealt with.

Nigel Newcomen said:

“I pay tribute to my staff who have worked so hard to enable me to deliver the commitments that I made on my appointment five years ago: to develop a new programme of learning lessons publications, to improve the quality and timeliness of fatal incident and complaint investigations and to do more with less. We will have to do still more in 2016-17. I know my staff will rise to the challenge.”

A copy of the report can be found here www.ppo.gov.uk.