Examination of Witnesses (Questions 1-19)
MS FRANCES
CROOK, MS
PAULINE CAMPBELL,
MS DEBORAH
COLES, MS
JULIET LYON
AND MR
GEOFF DOBSON
8 NOVEMBER 2005
Q1 Chairman: Good morning. Thank you
very much indeed for coming this morning to give evidence to us.
As you know, this is a one-off hearing that we are holding today
looking at the issue of prison suicides and their causes and,
in particular, their relationship to overcrowding in prisons.
I would be grateful if each of you could introduce yourself and
the organisation you are from.
Ms Lyon: I am Juliet Lyon and
I am Director of the Prison Reform Trust. I worked in adolescent
mental health for 15 years prior to taking this post.
Mr Dobson: I am Geoff Dobson.
I am Deputy Director of the Prison Reform Trust and a former Chief
Probation Officer.
Ms Coles: I am Deborah Coles.
I am Co-director of INQUEST, an organisation that works with the
families of people who die in custody. We conduct policy and research
arising out of those deaths and investigations.
Ms Crook: I am Frances Crook and
I am Director of The Howard League for Penal Reform.
Ms Campbell: I am Pauline Campbell
and I am a Trustee for The Howard League for Penal Reform, and
I am the mother of Sarah Elizabeth Campbell, aged 18, who died
at Styal Prison in 2003.
Q2 Chairman: Mrs Campbell, we are particularly
grateful to you for coming here this morning. I wonder if we could
start with you and you could set the scene for the whole of our
session today by telling us about the circumstances in which your
daughter died and what lessons you think can be learned from that
tragedy.
Ms Campbell: My daughter, Sarah
Campbell, aged 18, was sentenced at Mold Crown Court on Friday
17 January 2003 and found guilty of a non-violent offence. She
was taken to Styal Prison in Cheshire and put in the segregation
block, which I believe was a highly unsuitable place given that
she was seriously depressed and physically ill as well. It was
on the segregation block the following day, 18 January 2003, that
Sarah collapsed dying. However, before collapsing Sarah did tell
prison staff that she had taken a quantity of anti-depressant
tablets. Unfortunately there was a delay of between 20 and 40
minutes before staff summoned an ambulance, and this evidence
was highlighted at my daughter's inquest in January this year.
Unfortunately there was an argument between a prison officer and
a nurse about whose job it was to call the ambulance. When the
ambulance finally arrived at Styal Prison it could not get through
the prison gates and was held up for eight minutes. Consequently,
when paramedics reached Sarah she was already unconscious. She
was taken to Wythenshaw Hospital in Manchester, where she died
later that evening without regaining consciousness. The cause
of death was Dothiepin poisoning. Let me set her death in the
context of the deaths at Styal Prison. Sarah's death was one of
six deaths that occurred at Styal in the 12 months ending August
2003. Sarah's was the third death and she was the youngest at
age 18 to die. That is a summary of Sarah's death in the so-called
care of Styal Prison.
Q3 Chairman: So many things went wrong
according to that account. What is your view about the lessons
that can be learned and how systems could be changed so that it
was not possible for so many things in a row to go wrong, leading
to Sarah's death?
Ms Campbell: I think there are
three main points arising as far as I see it. Firstly, there are
far too many women being sent to prison for non-violent offences.
Nine out of 10 women are convicted of non-violent offences.
Q4 Chairman: Would you mind telling us
what sort of offence Sarah was convicted of?
Ms Campbell: Unusually, Sarah
was convicted of non-violent manslaughter. Sarah and another woman
hassled a man for money, it was a non-violent offence, but he
had a history of heart disease and, tragically, he collapsed and
died immediately following the incident. The court accepted that
Sarah had played a lesser part in the offence and so she received
a shorter sentence than her co-accused. I must stress that it
was non-violent manslaughter. She would have had to have served
12 months at Styal. In my opinion the women should be given community
sentences if only because they are usually more effective and
they cost less. Secondly, women offenders who are mentally ill
should not be sent to prison. Prison is a place of punishment
and these women actually need care, treatment and support. Thirdly,
in the case of someone like Sarah, I remain incredulous that she
was taken to the segregation block, the punishment block, on her
arrival at the prison when, in fact, she was seriously ill.
Q5 Chairman: So your emphasis is as much
on changing the patterns of sentencing and the appropriate accommodation
for offenders as it is on what happens inside the prison, although
that was clearly itself a significant factor?
Ms Campbell: Yes, that is right.
Q6 Chairman: Deborah, the Government
has said that "suicide prevention efforts are proceeding
with unprecedented energy and commitment and with some success".
Do you agree with the Government's assessment?
Ms Coles: A lot of work has been
done by the Safer Custody Group to address the issue. The figures
are shocking for us all. There are some very, very good policies
on paper; it is their translation into practice that is the problem.
I want to pick up on something that Pauline said. We monitored
the six inquests into the deaths of women at Styal. One of the
problems that the inquests exposed was the fact that five out
of six of those women were poly-drug users, ie they had serious
drug misuse problems. The majority of the women had been recognised
as having mental health problems. What the inquests also exposed
was the fact that the Prison Service had been warned by the Inspector
of Prisons, Anne Owers, of her concerns about problems at Styal,
particularly in terms of the treatment of women with drug problems
and the fact that there was a serious lack of detoxification facilities
available, and they had been warned about that over a year before
these six women died. Pauline waited two years before the inquest
was held into her daughter's death. That is the only public forum
in which these deaths are investigated and looked into and scrutinised.
What those inquests highlighted was the fact that there was a
real lack of awareness in suicide prevention within Styal Prison,
there were problems with staff training and there were problems
with staff's ability to work with some very, very damaged women.
All the policies and procedures were there. They had the F2052
suicide screening forms. The problem was that the policies were
not being implemented, which resulted in women, who were at serious
risk of suicide, being kept in the segregation unit. There are
some extremely good policies that have been worked on and they
are involving more people with mental health expertise. The problem
is how you translate those. While you continue to put women in
prison who are mentally ill I really do not think you can expect
the staff, who have really poor training and who do not have any
training in working with mentally ill women, to keep women alive.
Q7 Chairman: Juliet Lyon, what is your
view about the Government's overall claim of "unprecedented
energy and commitment"?
Ms Lyon: I think it is a fair
claim, but the results are still not as any of us would hope.
A success would be to radically reduce the number of suicides.
Although things are looking very much better this year, which
I think is a testimony to that unprecedented effort, it is still
true to say that we have got a very poor record in relation to
other countries. It is still true to say that people are not only
dying in prisons but also injuring themselves repeatedly every
single day. The levels of self-harm are extraordinary, particularly
in Young Offender Institutions and women's establishments. The
latest figure that we have from the Women's Team is that 587 out
of every 1,000 women in prison injure themselves repeatedly while
they are in custody.
Q8 Mr Streeter: Can anyone actually say
what the trends of suicide in prisons are like compared to trends
in suicide in people who are not in prison? Obviously that is
a troubling trend. Has anyone done any work on that?
Ms Crook: There is quite a lot
of work being done on that. There are lots of ways of calculating
it depending on whether you take the daily population or the throughput
of population. What is apparent is that the suicide rates in the
community are going down and suicide rates in prison are maintaining
their level and continuing to be extremely high, particularly
for people who have mental health problems and they are very,
very vulnerable. The other thing is that self-injury in prisons
is extremely high, much higher than it would be for the same sort
of population in the community and this is often a sign of distress
because of the nature of imprisonment, it is a reaction to custody,
so it is prison that is causing the self-injury. If you are in
a prison that is so grossly overcrowded and staff are so pressed
they cannot give you attention, the only way to get attention
is to do something dramatic and desperate and that behaviour is
carried out into the community afterwards. Whatever happens in
prisons is not separate from what goes on in the community afterwards.
Mr Dobson: There was an article
in the Lancet published earlier this year looking at suicide
levels in male prisoners from 1978 to 2003 and it found that the
suicide rate for men in prison is five times that for men in the
community and that boys aged 15 to 17 are 18 times more likely
to kill themselves in prison than the community. That obviously
reflects to a large extent the degree of vulnerability of the
populations.
Chairman: You have a huge amount of information,
but it would be very helpful if we could stick to answering the
questions that the members have rather than sharing all the information,
much of which is in the written evidence, otherwise we will not
get through many of the areas we would like to get on to.
Q9 Mr Streeter: We have heard the Government
is concerned about this and they are doing some good work. Do
you think their suicide prevention policy is embedded in every
aspect of prison life?
Ms Lyon: Since the new forms have
been introduced as a new way of trying to look at suicide prevention
it has raised awareness, there is no doubt about that, and 40
prisons are already implementing the new ACCT forms. I also think
it is fair to say that staff get a basic eight weeks training
in terms of their professional training, but that is so slight.
I think we are asking too much of our staff. We are asking them
to run a second rate health service within prison confines.
Ms Crook: Sometimes policies have
unintended consequences in practice. For example, the design of
safer cells means that there is virtually no ventilation in the
cells. For example, over the summer in Holloway Prison there were
pregnant women who were fainting and the Governor had to provide
fans and bottles of water for them. Last year when we had the
ministerial meeting there was virtually a riot going on upstairs
in Nottingham in the summer because the prisoners could not open
the windows. We were having a meeting on suicide prevention and
people were rioting in the safer cells upstairs. Sometimes the
policies are too mechanistic and not based on human need.
Q10 Mr Streeter: Is the crucial thing
a connection between overcrowding and suicide or are there other
measures unconnected with overcrowding which we also need to look
at?
Ms Lyon: I think it is possible
to prove a set of links between overcrowding and deaths in custody.
I do not think there is a single linear link. If you were to look
at staff knowing their prisoners, which must be one of the critical
things in relation to keeping people safe, because people are
moving from one jail to another people are not getting to know
their prisoners. Personal officer schemes have broken down in
very many prisons as has sentence management. All of these things
are ways of helping people see that they have a future and that
they have someone connected to them. Overcrowding in terms of
the pressure on staff and the high level of movement of prisoners
is one of the areas in which we can demonstrate the links and
although you could improve that slightly with staff training,
without reducing numbers and reducing this continual movement
you cannot create a climate of safety which is needed.
Q11 Mr Streeter: The new ACCT care-planning
system, is that good? Is it going to make a difference? Is that
the way forward?
Ms Coles: I think it is another
example of something that looks very good on paper. My concern
is the issue we have raised about staff training. It is a new
form, it requires another layer of assessment and it talks about
the importance of assessors who carry out the in-depth screening
of vulnerable prisoners. The concern is, in terms of overcrowding
and the impact on staff time, whether or not staff are going to
have the time to implement the policy as it is written on paper.
I think the policy has come about because of concerns about the
previous policy and it is supposed to be an improvement on that,
but unless we can actually ensure that staff are trained and aware
of the importance of the policy and have the time and resources
to implement it it will have similar problems to what the F2052
did in terms of staff not being aware and not being able to implement
it.
Q12 Gwyn Prosser: I want to stay with
the incidence of recently admitted prisoners committing suicide.
We have heard from Pauline Campbell about the need for extra training
and there has been some discussion about safer cells. Looking
at the various remedies, better training, safer cells, more staff,
which means more resources, is there a pecking order amongst those
which would have a bit more of a beneficial effect or does one
stand out starkly among the others, or do you have any other means
you might want to suggest to prevent a suicide in the first few
days and hours?
Ms Coles: It almost starts before
the prisoner actually arrives in the institution. One of the concerns
we all share is about what happens at court and the process of
either remand or sentencing particularly of people who are vulnerable,
be it because of drug and alcohol problems or because of mental
health problems. Information going from the court to the prison
establishment is very important. I cannot tell you how many inquests
I have attended where the prison has not been made aware of someone's
vulnerability because the relevant paperwork has not accompanied
the prisoner or the paperwork has arrived in the wrong bit of
the prison and so the person doing the assessment for suicide
has not got that information in order to carry out the assessment.
We need to go right back to the process of who actually arrives
in those prison gates and what information comes with those prisoners.
One of the concerns that I have is that when you have an inquest
all the attention is on the prison and the Prison Service. We
have got to look at the role of the judiciary here in terms of
the kind of people they are sending to prison so that we have
a more holistic way of trying to stop these deaths happening.
Q13 Gwyn Prosser: On that important point
of transmitting information, what is going wrong? Is it a system
which is not being used properly or is the system not working?
How would you improve that communication?
Ms Coles: I think it is a combination
of factors. Sometimes it is just individuals failing to ensure
that that information is physically passed to the right person,
sometimes it is forms not being filled out at all, people not
understanding their obligation and duty to fill out a form and
make sure that that accompanies the prisoner into the institution,
sometimes it is pure bureaucracy, administrative blunders because
people are not aware where that information should go or a fax
comes into the prison and it does not end up on the prisoner's
file. It is a variety of factors that is causing that problem.
Ms Crook: And a system under such
strain. It would be impossible to design an administrative system
that would cope with the numbers. The most important thing is
time for people. When you talk to prisoners they say that nobody
ever has the time to sit down and talk. We all sit down to talk
to each other. In prison nobody ever sits down to talk to somebody,
they are always standing and on the move. If you are coming into
prison from court—and do not forget, people kill themselves
in court cells and in transport in between, the transport system
itself is pretty awful—you arrive distressed, coming down
from drugs, you have a catalogue of problems and fears, you are
very, very frightened and lonely and you are whisked through a
system. If the administration works that helps, but in the end
you need someone to support you, you need someone to spend time
with you and explain things to you. Many prisons have first night
centres but many of them are run by charities. This is not the
state providing a decent service to people for whom it is accepting
responsibility at all. The system is very strained right from
the beginning to the end.
Mr Dobson: I do think we need
a national system of what some people call psychiatric assessment
panels and others call diversion schemes, one that is linked not
just to courts but to police stations, because often vulnerability
is displayed when people are first arrested and they are in the
process of being charged. A great deal is known about many of
these individuals in the community by families and by community
agencies. I think that sort of assessment panel at that very early
stage can bring the information together[1]
and then when some people do eventually go to prison that information
can go with them.
Ms Lyon: You asked what would
improve things. The introduction of the Insider scheme is a very
important one which has been introduced by the Safer Custody Unit.
It is modelled on the Samaritans Listeners' work which is where
prisoners are available to help one another. I was talking to
Insiders at Exeter Prison. I was very impressed with the work
the men are doing there and the seriousness with which they held
their job. I would like to echo what Frances said about transport.
I have heard complaints from staff continually about late arrivals
from court. Either they are very late, which makes the assessment
far too short and far too risky, or people are being held now,
because of overcrowding, overnight in police cells. A couple of
weeks ago on one particular night there were more than 100 people
detained in police cells simply because there was not the time
to get them from the court into transport and to a jail with places.
The overcrowding links are there.
Q14 Gwyn Prosser: Given the present system
and its weaknesses in terms of transmitting information, if a
new prisoner arrives in prison and his documentation is not in
place, what guidelines should there be for prisoners being received
without any background information?
Ms Lyon: Every prisoner should
be treated as at risk. It is a very inexact science trying to
predict the risk of suicide. If you look back at the deaths that
have occurred in custody, very many of them are not people who
have been identified as at risk. There are particular points in
their time in prison, early on and before leaving, when there
is an increased risk, but there is a bit of a danger in thinking
you can perfect the ability to predict rather than focus on improving
the overall environment and the procedures within it.
Ms Coles: The procedures are all
there. The policies that you are seeing make it quite clear that
everybody should be looked at as being a potential risk, but obviously
the benefit of having information from other outside agencies
is crucial in terms of carrying out a full assessment. I think
there should be a greater use by prisons of contacting prisoners'
GPs or drug counsellors or people from the outside to glean as
much information about the person as possible, but obviously that
has to take place in the early days of somebody being in the institution.
Q15 Mr Benyon: I want to talk specifically
about mental health provision. Based on the number of women prisoners
who are harming themselves and the horrific statistics from the
Prison Reform Trust about the number of prisoners who are admitted
with mental health disorders and you have talked about training
or the lack of it, what do you identify as the key gaps and how
does it compare with the provision that is available out there
in the community?
Ms Lyon: There is a commitment,
as you will know, given by the Department of Health and the Home
Office to provide equivalent mental health care within the system
to that outside in the community. We are about to publish a report
about men and mental health which I think reveals quite how wide
a gap there is to breach between community services and prison
services. I think the issue is principally how far we should be
trying to turn our prisons into healthcare centres and how far
we should be looking to the Department of Health to provide either
high level secure, medium secure or community psychiatric services
for offenders. In some ways I feel that we are looking in the
wrong place. Staff are now getting basic mental health awareness
but it is incomparable to the training nurses and doctors would
get entering the health service. It feels to me that we could
pour an awful lot of resources into the prison environment to
try and make it better at caring for the mentally ill, but the
question is why would we want to do that?
Q16 Mr Benyon: What effect does overcrowding
have in relation to mental health issues? Have you identified
this prison by prison?
Ms Lyon: We have done a number
of different pieces of research, one of which was to talk to all
the independent monitoring boards about what concerned them about
overcrowding in general and then specifically what concerned them
about the 18 to 20 year olds, which is a group that has been particularly
neglected in the prison setting. Again and again people were pointing
to increased distress, distance from home and a failure often
for prisons to understand the importance of family as a potential
resource. Certainly outside there has been a lot of very good
research at the University of Manchester in terms of how families
can help particularly young people in distress and vulnerable
to suicide, but that has not reached the prisons or it stopped
outside the gate in many ways. I think there are clear gaps that
could be improved there.
Mr Dobson: Particularly the amount
of movement of prisoners between prisons. It takes a while for
a prisoner to feel reasonably comfortable in an establishment
to be able to build up relationships with staff and other prisoners.
The number of movements is very disruptive and the incidence of
suicide after a movement is high.
Ms Crook: I do not know whether
the Committee is aware that The Howard League also has a law department
and we act on behalf of individual children in custody, taking
individual cases. We have been acting for some years for a young
girl who epitomises many of the problems both of juveniles, for
woman and for adult men as well who have mental health problems.
What we are asking for, as a result of her case, is a public inquiry.
This is unusual in that usually people ask for a public inquiry
once someone has died. "SP", as I am going to call her,
is not dead, she is still alive, but because her case is so tragic
we think it could illuminate many of the issues that you are drawing
attention to. She had mental health problems as a child and was
not picked up and dealt with properly and appropriately by Social
Services and by other services and she ended up in custody having
committed a rather nasty violent offence. She has got a five year
sentence. In her time in prison she had to be taken for something
like 20 blood transfusions because her self-injury was at such
a level. Eventually, after we took judicial review action, we
got her transferred to a secure mental hospital, but it took two
years and concerted legal effort to get her out of the prison
and into an appropriate place. This is the first time she has
got appropriate mental health care. There are many cases like
her. She is at the severe end. Getting people transferred from
prison to an appropriate mental health setting, whether it is
secure, semi-secure, open or whatever, is incredibly difficult.
The courts keep using prisons as a dumping ground for people who
sometimes have committed relatively minor offences, but it is
a health issue, it is not a criminal justice issue that is at
the heart of it.
Q17 Mr Benyon: The Home Office has commissioned
a Court Diversion and Healthcare project with the aim of spreading
this out across the prison system. How well do you think it is
working and what is its potential?
Ms Lyon: We are not sure this
has started yet. What we are aware of is that NACRO has done some
work to try and map out the existence of court diversion schemes
across the country and revealed an extremely patchy picture. These
court diversion schemes are the responsibility of the Primary
Care Trusts, but we cannot see any evidence that Primary Care
Trusts have these as any sort of priority. It is not a target
for chief executives of mental health trusts. Clearly, unless
it becomes something that PCTs feel that they absolutely must
do, it is going to slide down the list of priorities. Although
we welcome this new project, we are not clear it has begun. It
certainly needs to begin.
Chairman: We will ask the Minister about
that.
Q18 Mrs Dean: Frances, in your paper
you urge the Government to take concerted action now to reduce
the numbers entering custody, so as to get suicide numbers down.
You urge the need for more secure and semi-secure psychiatric
beds. Is the lack of such beds the reason for delays in transferring
prisoners to hospital? Have you done any estimate on the number
of extra beds that are required?
Ms Crook: We have not done an
estimate on the number of beds, but what we found is it is incredibly
difficult to find the range of care that is appropriate for young
people. We have represented a number of young people who have
had very serious mental health problems and they have been imprisoned
and it is very difficult to get them into some kind of accommodation
which is appropriate for them. There is a lack of that nationally.
I do not know how many beds there should be, but there should
be more because there are many children who are in penal custody
and who really need appropriate care and support because otherwise
their condition will not be dealt with, which is deeply unkind
to them, but, also, it will create dangers for their community
in the future because these young people could be potentially
quite dangerous unless they are helped.
Q19 Mrs Dean: What do you think is most
needed to ensure practical support and follow-up care when mentally
ill people leave prison?
Ms Lyon: We have been trying to
find schemes which demonstrate good practice. There is a scheme
in south-east London where there is a pathway worked out. Efforts
are being made, undoubtedly so, with the transfer of responsibility
to the Department of Health for prison healthcare, so trying to
make sure that people are registered with a GP, for example, trying
to make sure that they have got local links. There are certain
perceptible gaps. We know that when people leave jail and they
need to have drug treatment they need that there and then, they
do not want to be queued up for months waiting. There is a high
association with drug abuse and suicide. There is more work that
could be done. There are some examples of good practice around
the country. We think the North West NOMS pathway may have some
helpful findings on this. I could give the Committee some further
information on that afterwards.[2]
Chairman: That would be helpful. Thank
you.
1 Note by Witness: The panel could also divert
many people to treatment facilities. Back
2
Note by Witness: Efforts are being made to link NOMS offender
pathways with DH care programme approach. In the North West some
work has been done on confidentiality protocols, mental health
need and sentence planning. It is thought that more attention
needs to be paid at a national level to managing confidentiality
and information exchange and responding to the needs of offenders
carrying a dual diagnosis. The North West pathfinder has identified
that, by monitoring individual offenders, an offender manager
can also monitor health treatment and support on release from
custody. As yet there is no report on this issue. Back
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