Download Submission to EHRC on deaths in detention

Submission to the Equality and Human Rights Commission’s Inquiry into non-natural
deaths in detention of adults with mental health conditions
This submission is made by the Home Affairs Policy Adviser within the Mission and Public
Affairs Division of the Archbishops’ Council of the Church of England. It is not made in the
name of the Archbishops’ Council, or any official body of the Church of England. The
Church of England is actively engaged with the life of places of detention of every kind, and
this submission seeks to reflect views of a number of chaplains and other Christians
working in different capacities in the detention context.
Scope of the Inquiry
Although the title of the Inquiry refers to non-natural deaths of adults in detention, its remit
is confined to prisons, police custody and hospitals. It is regrettable that immigration
detention has not been included. In that sector, the number of non-natural deaths has not
been large, but the levels of distress and uncertainty among immigration detainees are high,
mental health issues are not infrequently present and are likely to be exacerbated by the
effect of detention, and these deaths have rightly received much public attention.
Non-natural deaths in hospitals are not considered in the present submission.
Suicide prevention in prisons – have staffing cuts been a factor?
It is too early to trace cause and effect in relation to the sharp rise in deaths in prison
custody over the last 18 months. Both the Chief Inspector of Prisons and the Prisons and
Probation Ombudsman (PPO) have recently acknowledged that this may be connected with
the sharp decrease in staffing numbers in prisons during the last four years. Research by
Prof. Alison Liebling and others in 2005 said that ‘a 12-prison suicide prevention study
suggested that mean levels of distress among prisoners were correlated significantly with
institutional suicide rates1. Staff-prisoner relationships were an important contributory
factor in levels of distress. Where there are fewer staff than previously, and where (as in the
last few years) there has been an exodus of many of the most experienced staff, the impact
of staffing cuts on staff/prisoner interactions and so on the ‘survivability’(Liebling’s word)
of a prison may turn out to be significant. At the same time, it must be acknowledged that a
large recruitment exercise is currently in progress, so that the numerical shortage of staff,
especially severe at present in prisons in the South East, is likely to improve.
The ACCT system and those with mental health conditions
The PPO asserted in his latest annual report (Sept 2014) ‘I believe that it is time to review
and refresh the current suicide prevention arrangements in prison’. The Assessment, Care in
Custody and Teamwork process (ACCT) has been in place in prisons (and in a slightly
adapted form in immigration detention) for almost a decade, and on the whole it is well
bedded in. ACCT was itself an improvement on the previous (2052SH) system, and it has
become a method of managing self-harm risk which is well understood by many staff and
1
Alison Liebling, Moral performance, inhuman and degrading treatment and prison pain, in Punishment and
Society 13(5), Sage 2011, p.535.
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many levels, including prison (and custody) officers. (The ACDT system used in
immigration detention centres was drawn form, and is (mutatis mutandis) almost identical
to the ACCT system.)
It is not clear that the ACCT system needs a thorough overhaul. A great deal of training
time has gone into this system over the years. Any substantial change would entail a further
round of training of all operational staff, at a time when resources are so stretched that time
for training is very hard to find. Such time as is available would be better spent on training
in mental health awareness, linked to risk of self harm and suicide. It seems from PPO
investigations that self-inflicted deaths in custody, where an ACCT was not open, have
often involved some inability of staff to spot signs of suicide risk in the first place.
There are two opposite risks in relation to the ACCT system, especially in relation to those
with mental health conditions. Firstly, ACCT forms may be too readily opened in cases
where a person has simply said or shown that they are feeling low in mood. If too many
ACCTs are opened, the focus on truly risky individuals can be diluted, and ACCT can at
worst become a back-covering exercise for the institution, or individuals within it, since in
the event of a death ‘we did open an ACCT’ is objective evidence that staff were on the
case. At the opposite end, if ACCT is only opened where the person has credibly declared
that they are likely to self harm or take their own life, too many people will slip through the
net. In many establishments, managers are familiar with these risks. There is not always
sufficient participation by hard-pressed mental health professionals in the ACCT process,
especially the early stages.
Recommendation: When there is consideration whether a person who is on the mental health
team’s caseload should be placed on an ACCT, a mental health professional should
normally be involved in the initial assessment and drawing up of the care plan, as well as in
subsequent reviews.
Peer support
There is growing use of prisoners to support their peers in prison. Proper attention is
normally paid to the assessment and management of risk, so that peer supporters do not
misuse their access to less expert or more vulnerable prisoners. Some prisoners with mental
health conditions can be vulnerable to improper use of peer support roles by others. In the
case of Listeners schemes, local Samaritan groups very often provide essential support in
selection, training and supervision of the listeners. This depends both on the resources of
the local group, and on the willingness of prison managers to facilitate such support. There
is no doubt that Listener schemes have saved many lives. Listener groups have been much
easier to sustain in training prisons than in local prisons, since the turnover of prisoners is
less; this is unfortunate, since the risk of suicide is much higher in the early days of custody,
or straight after conviction/sentencing.
In addition to Listeners, prisoners are increasingly used as Insiders (supporting reception
and induction processes), as buddies and in similar roles. Prisoners trusted to carry out
these roles should also be given appropriate support, training and supervision, and in
particular they must be trained in and aware of the needs of those suffering from mental
health conditions: they should certainly not just be used to plug gaps in the ever-thinner red
line of frontline staff.
Recommendation: All prisoners carrying out peer support roles should do so with
appropriately validated systems for selection, training and supervision, and these roles
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should be defined, coordinated and monitored on a consistent and proper basis at national
and regional as well as local levels.
Isolation
A significant number of prison suicides take place in segregation units. It has for some
years been NOMS policy that people on ACCT should only be held in a segregation unit in
exceptional circumstances. The only clearly legitimate scenario is where a person poses so
grave a risk of imminent serious physical harm to any other person, that that risk can only
be managed by solitary confinement. Such cases are exceptional indeed. Too often people
on ACCT are segregated because their behaviour is unusual, or disturbing, or unhygienic, or
non-compliant, or because they demand to be segregated, or because they damage property.
Very often such behaviours may be linked to mental health conditions.
In police cells, isolation comes as standard. Even where a detainee is recognised to be at
risk of self harm, staff may rely on in-cell cameras to hep them ensure safety. Very rarely
do staffing levels permit that a member of staff continuously watches the bank of CCTV
monitors. The effects of alcohol or drugs are frequently an additional risk factor in police
custody, and use of these substances to self-medicate on the part of those with certain
mental health conditions is not unusual. There has been growing awareness among custody
staff of the need for vigilance and early intervention in such cases, especially through the
use of the ‘four R’s’2
Even where a person is placed under constant one-to-one supervision, the effect of isolation
is by no means always nullified. In prisons, police custody and other settings, the member
of staff often engages with the person in such a way as to provide supportive human
contact; but it is not unusual to see the member of staff sitting outside the cell – not always
even with the door open – making almost no attempt to engage the detainee personally. In
police custody, it is not unknown to see an officer from a response or similar team, perhaps
not custody trained, detailed to carry out the constant watch, and taking very little interest in
the person they are ‘watching’.
Recommendation: Detainees who are at risk of self harm, especially if there are associated
mental health issues, should not be made to experience personal isolation from their peers
or from any human company, unless it is unavoidable for reasons of risk.
Mental health services
There has been some progress in providing mental health interventions in the custodial
context. The move towards NHS commissioning, in prisons and more slowly in police
forces, should in principle speed progress towards parity of service in the community and in
custody. The chief difficulty is that they have been patchy and inconsistent.
Prisons - the Mental Health Inreach system in prisons has been a success: although
potential caseloads are often too high for the mental health professionals in the team, there
has been a considerable impact. The Secretary of State for Justice has recently declared his
intention of introducing new specialist mental health services in prisons: this could well be a
promising development. There has also been good progress in many places in bringing
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The officer tests for rousability, response to questions, response to commands (and sometimes touch), and
remembers other conditions that can be masked by alcohol such as diabetes, overdose, epilepsy or head injury)
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down the waiting periods for those prisoners who are referred to, and for those accepted by,
NHS secure facilities. However, there is still plenty of unmet need in terms of people with
mental health issues in prison.
Police custody – there are a number of examples of good joint working between police and
the NHS at force level. Ten forces were funded for pilot schemes trialling an extended
mental health nurse service, and these have had a considerable impact, especially in
reducing the number of people held in [police cells under Section 136 of the Mental Health
Act 1983. There are further experiments with triage nurses accompanying police officers
on patrol. Such liaison and diversion schemes have great potential, and need to be
mainstreamed across the country.
Joint working between police and health services needs to be centred on the protection and
best interests of the person involved, as well as of the public. Section 136 detentions in
police custody are still too frequent. In the 10 years to 2008/9, 17 people died while thus
detained. NHS provision of Section 136 suites is patchy, sometimes not in practice
available 24/7, and the provision for young people is especially inconsistent. The recent
‘Concordat’ on mental health crisis care (February 2014) needs to be operationalized in
every part of the country.
Recommendation: The spread of NHS commissioning of health services in prisons and
police custody should be used to ensure both consistent quality and continuity of care as
people move into, through and out of the criminal justice system. CQC should monitor this.
Race and nationality
We know that black, and minority ethnic people are over-represented in our prisons. We
also know that black African and Caribbean men are over-represented a the ‘hard end’ of
mental health services, with higher rates of detention under the Mental Health Act; but they
are under-represented in prison mental health team caseloads; also, ‘black mental health
patients are twice as likely as non-black patients to experience criminal justice agency
involvements in their pathways to care during First Episode Psychosis’3. The ‘Delivering
Race Equality’ programme of 2005-2010, though commendable, seems to have achieved
little by way of improved outcomes, and there is no current government policy in relation to
BME mental health inequalities, although the government action plan for mental health
includes some measures to address the problem.
According to Inquest, a disproportionate number of those who die in or following police
custody, following the use of force, are from BME communities.
Training of staff about the risk factors lying behind the number of deaths of BME men has
generally centred on the higher vulnerability of some sectors of that population to harm
through physical restraint, especially in the form of positional asphyxia. While attention to
maintaining the airway and ensuring that the person is breathing, and able to speak, is very
important, there needs also to be attention to any other factors that may be involved. It is
relevant to compare the fact that BME prisoners are consistently, across the country, overrepresented in segregation and use of force by staff: this can only be caused by differential
treatment by staff. It is not unusual to hear staff stereotyping black prisoners by saying that
they tend to be ‘big’, or ‘loud’, or ‘in your face’.
3
Research cited in Ethnic inequalities in Mental Health, Lankelly Chase etc., London Feb 2014
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There may be a similar issue with non-UK nationals. In 2012, for example, 22.8% of
suicides in prisons were foreign nationals: overall, the proportion of foreign nationals in the
prison population was about 14%.
Recommendation: Across the criminal justice system, data should be collected on the
proportion of non-natural deaths where the person is from a BME community or is a foreign
national, and on the presence of a mental health condition, in such a way as to enable multifactorial analysis.
Personality disorder
The phrase ‘mental health conditions’ should be understood to include personality disorders
(PD). Many types of PD are likely to raise the risk of suicide, particularly in the context of
custody. It should not be difficult to confirm this by analysis of the rate of suicide in PD
units. Suicidal ideation is said to be especially prevalent among those with Borderline
Personality Disorder, and a propensity to self harm is listed as a core feature of BPD in both
DSM-5 and ICD-10. Several other forms of PD are also associated with raised risk of self
harm. It is also the case that some forms of PD can raise the risk of violent actions, and so
increase the possibility of homicide as well as of self-inflicted death. It is important that PD
is taken into account, as well as mental illness, in this enquiry. Many of those who exhibit
negative and destructive and/or self-destructive behaviours in prison segregation units or in
seclusion rooms in other settings, have been diagnosed with PD rather than treatable mental
illness.
Recommendation: Measures to analyse and address the risk of non-natural death among
those with mental health conditions should include (using appropriate clinical thresholds)
people with personality disorders.
Mental health awareness
In evidence to the Home Affairs Select Committee recently, a police Inspector with wide
experience of the issues around mental helath said that on average, a police officer in their
career will have redceived between 4 and 8 hours of mental health awareness training
(including initial training). Because police officers so often act as the last-resort emergency
service when people are behaving in a risky or disturbing way or showing distress, they
need to
Recommendation: Mental Health awareness refresher and update training should be part of
the annual cycle of mandatory training for police officers, and for all staff directly involved
in the care of detained people.
Martin Kettle
Home Affairs Police Adviser
Mission and Public Affairs Division
Church House, Great Smith Street, London SW1P 3AZ
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