Female prisoner deaths rising and prisons must take action, says Ombudsman

Prison staff must take action to prevent further prison suicides among women, after 12 took their own lives in 2016, said Prisons and Probation Ombudsman (PPO) Nigel Newcomen. Today he published a bulletin on lessons that can be learned from his investigations.

Prisons and Probation Ombudsman, learning lessons, deaths in custody, women prisoners

Download PPO’s learning lessons bulletin: self-inflicted deaths among female prisoners.

Prompted by the recent rise in self-inflicted deaths of women in prison, the bulletin reviewed 19 cases between 2013 and 2016 where women took their own lives. This small sample cannot explain this rise, but does identify a number of important areas of learning, including: better assessment and management of risk, improving suicide and self-harm prevention procedures, addressing mental health issues, combating bullying and ensuring timely emergency responses.

In 2015, for the first time since 2007, women had a higher number of self-inflicted deaths per 1,000 prisoners than men. Overall, deaths of female prisoners more than doubled in 2016 compared to the previous calendar year. This rise shows little sign of abating.

Ministry of Justice research has shown female prisoners report poorer mental health than males across a range of disorders and that almost one in two reported having attempted suicide in the past. This was more than twice the male rate and more than six times the rate of women in the community, as reported in other research.

After the deaths of six women at Styal prison over 13 months in 2002 and 2003, Baroness Corston was appointed in 2006 to conduct a review into the experiences of vulnerable women in the criminal justice system. Her inquiry became a significant milestone in the history of female incarceration in the UK. Corston argued for a complete rethink of the criminal justice system’s approach to women. The report made 43 recommendations, most of which were accepted by the government. In the years that followed, self-inflicted deaths among female prisoners ranged between one and three per year. However, in 2015 there were seven such deaths and the number continued to rise in 2016, reaching 12 by the year end.

The bulletin highlights important themes and lessons, many of which are a reminder to prisons of what already appears in their own rules and processes and have been made before by the PPO.  Among those lessons are:

  • prisons should ensure vigilance in risk management, proactively identifying suicide and self-harm risk based on established risk factors and triggers particular to the individual, and not just relying on how they present themselves to staff;
  • where risk is identified, prisons should implement the care-planning system to support prisoners at risk of suicide and self-harm (known as ACCT) effectively, and with appropriate management oversight;
  • prison mental health services should ensure that all cases are treated with an appropriate degree of urgency, and avoid delays with assessment and care;
  • prisons should ensure officers are vigilant for signs of intimidation or drug misuse to protect prisoners’ safety. Bullying is often related to drug debts, so where drug activity is suspected, staff should be on the lookout for signs of bullying;
  • prisons should ensure that ambulances are despatched without delay in the event of medical emergency; and
  • prisoners should ensure all staff, including night shift staff, carry cut-down tools.

Nigel Newcomen said:

“I find it disheartening that many of the lessons we identify to prevent women in custody from taking their own lives repeat those in previous publications from my office. This suggests it is not knowledge that is the issue, but a lack of concerted and sustained action. While we often identify examples of excellent and compassionate care by individual staff, and also recognise that prisons have been under enormous strain in recent years, there can be no excuse for not implementing essential safety arrangements that could ensure vulnerable women are better protected.

“It is to be hoped that delivering safer outcomes for women (and men) in prison will be at the heart of the Government’s new prison reform agenda, and that this bulletin can assist with this and help to reverse the unacceptable and tragic rise in self-inflicted deaths.”

Download the complete news release.