Suicide in custody

Suicide in Specific Sub-groupS

Suicide in custodyJenny Shaw

pauline Turnbull

AbstractSuicide in prison is a major concern. previous research showed that

the factors associated with prison suicide were being white, male, and

on remand. The most common method was asphyxiation, and around

half of the suicides occurred in the first month of imprisonment. Most

individuals had a history of drug and/or alcohol misuse, had received

a psychiatric diagnosis at reception into prison, and several prisoners

had secondary diagnoses, suggesting complex mental health needs. The

current prison suicide prevention policy aims to monitor risk and plan

the care of at-risk individuals using the Assessment, care in custody,

Teamwork (AccT) plan, which was fully implemented across the whole

prison estate in 2007. The AccT plan ensures a fast first response and

the provision of flexible individual care. it is supported by improved staff

training in assessing and understanding at-risk prisoners. The recent

changes to policies regarding deaths in custody may influence a reduc-

tion in rates of suicide. As these changes have been fully implemented

only relatively recently, it may be some time before their impact is

reflected in the rates.

Keywords AccT; custody; mental illness; policy; prevention; prison;

suicide

Suicide trends in the prison population

The prison service refers to consciously self-inflicted (CSI) deaths as opposed to suicides. The definition of CSI deaths includes all instances where it appears that the prisoner has acted to end their own life. The definition is broader than the legal definition of suicide, and includes some deaths that do not receive a suicide or open verdict at coroner’s inquest.

Jenny Shaw MBChB PhD FRCPsych is a Professor in Forensic Psychiatry

and Consultant Forensic Psychiatrist at Guild Lodge, Preston, UK.

She qualified from Manchester University and trained in general and

forensic psychiatry in Australia and north-west England. Her research

interests include homicide and prison mental health. Conflicts of

interest: none declared.

Pauline Turnbull MSc is a Research Associate for the National

Confidential Inquiry into Suicide and Homicide by People with

Mental Illness, Manchester, UK. She qualified from the University of

Manchester, and is currently the project lead for a study into sudden

unexplained death amongst psychiatric in-patients. Conflicts of

interest: none declared.

pSYcHiATrY 8:7 26

Numbers doubled between 1982 and 1998 and continued to rise.1 The number of CSI deaths fell between 2004 and 2006 (with the lowest numbers in 2006 since 19962), but rose again in 2007, with 90 self-inflicted deaths being reported in English prisons.3 There is a need for caution when drawing conclusions from fluc-tuations in numbers over a relatively short time period, and it is only by looking at figures over longer periods that conclusions on longitudinal trends can be established.

The prison service developed its own suicide prevention tar-gets, aiming for a 20% reduction in the rate of suicide from a baseline of 141 per 100,000 in 1999–2000 to a rate of 112.8 by April 2004. The target was not met: the rate of suicide in 2004–2005 was 121 per 100,000. However, the 3-year average annual rate of self-inflicted deaths in prisons for England and Wales was reported as 105.3 per 100,000 population in 2007.2 The 3-year average suicide rate for the general population is 8.3 per 100,000 for 2004–2006, suggesting an excess of suicides in prisons.3 There is a need for some caution in converting raw figures into rates, because of criticism and uncertainty about the denominator used to calculate rates (the daily average population of inmates).4

Suicide is more common in male than in female prisoners. A study that attempted to quantify the excess of suicide in male prisoners in England and Wales between 1978 and 2003 in com-parison with the general population reported an overall standard-ized mortality ratio (SMR) of 5.1, indicating a five-fold excess of suicide in the male prison population. This was much higher for males aged between 15 and 17 years, with an SMR of 18. These SMRs increased steadily throughout the sample period.5

It has been suggested that the high rates of suicide in prisons is not unexpected given the vulnerability of prisoners,3,6–12 who, as a group, have a multitude of risk factors, including: • high rates of substance misuse • mental illness • previous self-harm.

Characteristics of those who die by suicide in custody

The majority of the studies investigating CSI deaths in prison have been descriptive case series.

Sociodemographic and criminological characteristicsTable 1 shows that the majority of suicides in England and Wales are by white males.13–17 By far the commonest method used was death by asphyxiation, with the commonest ligature being bed-clothes attached to cell fittings.17 In the authors’ previous study, 49% of the sample was on remand, although remand prisoners represented only 19% of the overall prison population.17 Other studies have also shown that in around half of cases death occurred in the first month of imprisonment.13–17

Prison environmentSeveral researchers have suggested that features of the prison environment may be an important risk factor for suicide. A study comparing the characteristics of prisoners who had attempted suicide with those who had not, found few socio-economic differences. However, those who attempted suicide perceived themselves to be ‘worse off’ than their peers, spent longer in their cell, and experienced more difficulties with other prisoners (e.g. bullying/persecution).18 One limitation of this study is that

5 © 2009 published by elsevier Ltd.


Consiously self-inflicted deaths

Topp 197913 Backett 198714 Dooley 199015 Dooley 199116 Shaw et al 200317

Period studied 1958–1971 1970–1982 1972–1987 1972–1987 1999–2000

Sample size (n) 775 33 346 295 172

SociodemographicsMale 775 (100%) 33 (100%) 337 (97%) 290 (98%) 159 (92%)

White 247 (84%) 153 (89%)

History of alcohol misuse 55 (30%) 85 (29%) 46 (31%)

History of drug misuse 21 (11%) 69 (23%) 95 (62%)

Reason for convictionViolent crime 53 (7%) 50 (17%) 41 (26%)

Sexual crime 30 (10%) 15 (9%)

Homicide 56 (19%) 11 (6%)

Method of deathAsphyxiation 168 (90%) 302 (87%) 266 (90%) 159 (92%)

Time of deathevening/night 98 (53%) 149 (43%) 147 (47%) 83 (48%)

Within first month of

incarceration

77 (41%) 20 (61%) 84 (29%) 88 (51%)

Penal statusremand 69 (37%) 19 (58%) 153 (45%) 30 (11%) 84 (49%)

Where no figures appear in columns, the variable was not described in that study.

percentages given are valid percentages.

Table 1

factors related to mental illness were not examined. It has been suggested that prisoners have major social problems coming into prison, which are exacerbated by the prison environment and can contribute to suicidal behaviour.10 Other authors have suggested that a better prison environment and improved staff training are essential first steps in reducing the prevalence of suicide in custody.19–22 Further studies are required to examine the impor-tance of the prison environment as a risk factor for suicide.

Substance misuseSome 62% of suicides have a history of drug misuse, and 31% a history of alcohol misuse before entering prison.17 These figures are unlikely to be higher than the rates of alcohol and drug mis-use in the prison population as a whole.23 However, those with a history of drug misuse and those who were dependent on drugs were more likely to die in the first week after reception into prison.17 This has potential implications for the provision of good assessment and detoxification services within prisons.

Psychiatric historyThe prevalence of mental illness in the prison population is higher than in the community.23 The majority of prisoners interviewed for the national survey had at least one secondary diagnosis, and only 1 in 10 prisoners showed no evidence of any of the disorders surveyed. The authors’ study found that 72% of suicides received a psychiatric diagnosis at reception into prison, the most com-mon being drug dependence.17 Thirty-two per cent had one or

pSYcHiATrY 8:7 26

more secondary diagnoses, suggesting complex needs; 30% had previous contact with the mental health services.

Case–control studies into suicide in custody

Two studies have employed multivariate statistics in order to investigate the unique contribution of risk factors to the outcome of suicide in custody.24,25 A Dutch study reported that a combi-nation of being aged over 40 years, being homeless, having a history of psychiatric care, having a history of drug abuse, hav-ing one previous incarceration, and having committed a violent offence could correctly classify the majority (82%) of suicides.24 However, similar combinations of risk factors did not have the same high predictive value when the authors applied them to samples in the USA and UK, suggesting that further case–control studies are required. Recent Austrian research found that the factors showing the strongest positive associations with suicide in custody were a history of suicidality, psychiatric diagnosis, prescription of psychotropic medication, a highly violent last offence, and being in single-cell accommodation.25 In a recent systematic review, the most important risk factors associated with suicide in prisoners were occupation of a single cell, recent suicidal ideation, a history of attempted suicide, and having a psychiatric diagnosis or a history of alcohol misuse.26 These find-ings highlight the importance of addressing mental health and prison environmental factors in reducing suicide in the prison population.



Prison service monitoring and management of self-harm risk

After piloting in five custodial establishments in 2004,27 the Assessment, Care in Custody, Teamwork (ACCT) care plan-ning system for prisoners at risk of suicide and self-harm was introduced across prisons in England during 2005–2007, and implementation was complete by April 2007.3 The ACCT plan replaced the previous ‘Self-Harm At-Risk’ F2052SH form. A comprehensive audit of the efficacy of the F2052SH system found that, although the process targeted an at-risk group of prisoners with a level of mental health pathology similar to that found in general mental health services (as measured on the Brief Psychiatric Rating Scale (BPRS)), there were also high levels of ‘unmet need’ (i.e. undetected prisoners with similar needs who were not on an F2052SH). The care planning ele-ments of the F2052SH document were criticized, with 50% of the care plan actions not assigned either to an individual or a department. The review recommended a radical overhaul of the system of screening, monitoring, and care of prisoners at risk of suicide or self-harm, leading to the introduction of the ACCT.28

As with the F2052SH form, an ACCT plan can be initiated by any member of staff who has recognized that an individual is at risk. The at-risk individual is then interviewed by a trained assessor, and a care and management plan (CAREMAP) is drawn up within 24 hours of the concern being raised. All staff are required to read the CAREMAP of at-risk prisoners, and to record events, conversations, and observations in the ongoing record. A case manager is assigned to ensure that all care plan actions are completed and reviews attended by the prisoner are arranged proportional to need. This system ensures a faster first response and the provision of flexible individual care, and is supported by improved staff training in assessing and understanding at-risk prisoners.3

Where do we go from here?

The current prison service policy for preventing deaths in cus-tody originated from the ‘Review of suicide and self-harm in cus-tody’ by Her Majesty’s Chief Inspector of Prisons in 1990.29 A subsequent review of the behaviour and characteristics of female prisoners who attempted suicide or self-harm, and the recom-mendations derived from this study, led to the previous policy in 1994.30 An updated policy was published in October 2007, incor-porating ACCT, utilization of cross-agency strategies and safer custody teams to develop and implement continuous improve-ment plans, and more established areas of suicide and self-harm prevention such as peer support schemes.31

Changes to the prison regime as a whole have been recom-mended, including the removal of potential ligatures and ligature points.17 The recent ‘Suicide prevention and self-harm manage-ment’ policy suggests that safer cells (e.g. cells designed to reduce potential ligature points and types) can assist staff in managing those at risk of suicide. However, safer cells cannot deal with the problems underlying a prisoner’s behaviour, and thus can only complement a care plan for an at-risk prisoner.31 The policy also recommends that all officers, governors, and uniformed staff carry personal issue tools to cut down prisoners in the event of an attempted suicide by hanging or strangulation.

pSYcHiATrY 8:7 26

In 2004, the Joint Committee on Human Rights published a report on ‘Deaths in custody’ and suggested that there was a need for a system to capture learning points across sectors, following such deaths.32 From this, the independently chaired Forum for Preventing Deaths in Custody was established in 2006, with the primary aims of identifying learning opportuni-ties arising from deaths across the various custodial sectors, and preventing future deaths. A recent independent review has criticized the forum for its lack of authority and for being too large and diverse to be effective as a decision-making body.33 The review suggested that the forum be replaced by an Indepen-dent Advisory Panel on Deaths in Custody, comprising a small group of relevant experts. Since 2004, every death occurring in prisons, young offender institutions, probation-approved prem-ises, and immigration removal centres has been investigated by the Prisons and Probations Ombudsman. When there has been a failure of care, recommendations for improvements are made.

Evaluating the changes

There is evidence to suggest that the introduction of policies to deal with deaths in custody can have an effect on rates of suicide in custody. For example, prison suicide rates fell following the introduction of an integrated system of mental health referral, evaluation, and care in New York prisons in 1985.34 In the UK, an anti-suicide strategy introduced in 1997 at the Cornton Vale Scottish Women’s Prison was successful in raising staff morale, with ‘problem ownership’ helping to secure staff involvement ‘from the bottom up’.35

The recommendations for radical change in screening, assess-ment, and care planning for those with mental health problems and those at risk of suicide/self-harm in English and Welsh prisons have some face validity. As these changes have been fully implemented across the whole prison estate only relatively recently, it may be some time before their impact is reflected in the rates.

Future research

The case–control studies investigating CSI deaths have high-lighted the importance of improving mental health care within prisons.24,26 When an individual has been recognized as being at risk and placed on an ACCT plan, it is important to identify potential early warning signs. This means that, if these factors reappear when the individual is no longer on an ACCT plan, monitoring and mental health care input can be reintroduced. There is also a need to investigate further the impact of prison environmental factors such as single- versus double-cell accom-modation on risk, as well as evaluating the impact of addressing the social needs of prisoners. ◆

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Suicide in custody