Joint Committee On Human Rights Third Report

3 Scale of the problem

38. The number of people dying in custody, particularly by their own hand, is extremely shocking and concerning. The number attempting suicide is on average twice that of those dying in custody, and the number carrying out incidents of self-harm should be a cause of huge concern. Moreover, close analysis of the figures reveals not only that many in custody have mental health problems or drug and alcohol dependencies, but that they have presented themselves to the authorities with these problems before they have offended. This begs two fundamental questions; first, whether intervention earlier could avoid custody later, secondly whether prison is the most appropriate place for them to be kept in custody if custody is necessary. But it also highlights certain straightforward practical concerns—such as the vital importance of prisoners receiving close supervision and observation at the beginning of their sentence, a topic that will be returned to in Chapter 5.

39. It is within this context that the positive duties of Article 2 become of extreme relevance and importance. A pro-active approach is vital in order to reduce the rate of self-inflicted deaths among people in custody and help the state meet its obligations under the Human Rights Act.

40. There is a great deal of information about the incidence of deaths in custody, much of which we summarise below. However, we also note some serious deficiencies in the information which is collected, rectification of which could assist in preventing deaths in custody. In these cases it could be argued that the relevant authorities are neglecting their duty to take all reasonable steps in furtherance of their positive obligation to protect detainees' right to life under Article 2 ECHR.


41. In the five-year period between 1999 and 2003, a total of 434 prisoners in England and Wales took their own lives, equivalent to one every four days. During 2003 there were a total of 94 self-inflicted deaths in prisons in England and Wales, of which 80 were men and 14 women. In addition, in 2003 one prisoner was killed by a fellow inmate and 76 died of natural causes.[31]

42. In addition, as we shall see, around eighty people every year die from unnatural causes whilst detained under the Mental Health Act. Overall then, someone is either killed, kills themselves or dies in otherwise questionable circumstances—every other day. That—quite frankly—is shocking.


43. The Prison Service uses the term "self-inflicted death" rather than "suicide" when referring to those prisoners who take their own lives while imprisoned. This is because it does not differentiate between the occasions where there is an official Coroner's verdict of suicide and other occasions where people die at their own hand, for example through misadventure. As a result, the Prison Service records around a third more self-inflicted deaths than it would if it measured only suicide verdicts given by Coroners.

44. The 94 self-inflicted deaths in England and Wales in 2003 compare with 95 in 2002, 73 in 2001, 81 in 2000 and 91 in 1999. Figures from 2004 so far suggest that the total will increase this year.[32] In Northern Ireland, there were four self-inflicted deaths in 2003-04, 2 in 2002-03, none in 2001-02, 2 in 2000-01 and 5 in 1999-2000. In Scotland, there were 6 self-inflicted deaths in prison in 2003, 10 in 2002, 11 in 2001, 14 in 2000 and 13 in 1999.[33]

45. While there have been increases in the numbers of self-inflicted deaths in prisons, this must be set in the context of an increasing prison population. The Prison Service asserts that the rate of self-inflicted deaths is not increasing but has remained fairly stable. In 2002-2003 the rate of self-inflicted deaths in prisons in England and Wales was 146.9 per 100,000—significantly above the Prison Service's own Key Performance Indicator of 105 per 100,000. However, we were told by the Prison Service that the indicator that they regarded as the most reliable measure of the progress that they were making in reducing self-inflicted deaths was a three-year rolling average. This rate is currently running at 129 per 100,000.[34]

46. The majority of the organisations and individuals from whom we heard during the course of our inquiry expressed serious concern at the high levels of self-inflicted deaths amongst prisoners. In their evidence to us, the Royal College of Psychiatrists—which, in February 2002, published a comprehensive report 'Suicide in prisons'—stated that: "These rates are unacceptably high and the trend is alarming, especially given the amount of time and effort that has been spent in trying to reverse the trend".[35]

47. The Royal College also presented us with evidence making comparisons between the suicide rates of prisoners, offenders in the community and the general population. They told us that—

    [P]risoners cannot be compared with the general community as the prison population is characterised by younger age, lower social-economic status, histories of serious disadvantage and high rates of mental disorder—all of which make a population much more likely to have high rates of suicide. High levels of self-inflicted deaths in prisons could therefore be fully explained by the fact that prisons are simply importing a highly vulnerable population, who commit suicide at higher rates than other individuals wherever they happen to be.[36]

48. The Royal College told us that while some attempts have been made to compare prisoners with offenders who are supervised in the community, these attempts are unfortunately not really valid because prisons have high rates of turnover whereas community groups, even of offenders, are relatively stable. Moreover, prisons take the more serious offenders and community and offender groups may have a different age and sex profile, and different rates of drug and alcohol abuse.

49. The Royal College also drew our attention to a Home Office research study which found that offenders in the community had an overall death rate of about double that of prisoners and four times the male general population. The accidental death rate for offenders in the community was more than five times that of prisoners, and the homicide rate was as much as nine times higher. What evidence there is—at least superficially—might suggest that prison is a protective factor for a highly vulnerable and suicidal population. However, the Royal College again noted that such conclusions can be misleading as community studies are not satisfactory comparisons for the general population.

50. Whilst we accept that overall rates of self-inflicted deaths in prisons are not rising, increased reliance on imprisonment means that the total number of self-inflicted deaths in prisons each year is unacceptably high. This is despite the high priority that has been given to the issue and must be seen in the context of suicides in the general population having fallen to an all-time low.

Who dies in prison?

51. Prisoners who take their own lives are disproportionately drawn from certain sections of the prison population. An understanding of the profile of these statistically vulnerable groups is essential to any strategy to reduce deaths in prisons, provided that it is underpinned by individual risk assessments.[37]

  • Age. Most deaths during 2003 occurred in the 25-39 age groups. In all, more than a third (36 per cent) were in the 30-39 age group. The youngest prisoner to take his own life was 18 and the oldest 62. No juveniles (15-17 year olds) died but 11 young offenders (18-20 year olds) did. This is similar to the age-profile of those who died in previous years and broadly reflects the age-profile of the general prison population. Between January 1990 and December 2003, there were 177 self-inflicted deaths of young people in prison—19 per cent of the total of all self-inflicted deaths for that period.
  • Gender. Despite making up just over 6 per cent of the prison population, 15 per cent of self-inflicted deaths in 2003 were of female prisoners.
  • Ethnicity. A disproportionate number of self-inflicted deaths occurred amongst white prisoners. In all, 86 of the 94 prisoners who died in 2003 were white (91 per cent), even though white prisoners comprised around 78 per cent of the prison population. Four of those who died were Asian (4 per cent), three of those who died were Black (3 per cent) and one was Chinese. These figures are consistent with previous research findings which indicate that white prisoners are more likely to take their own lives.
  • Nationality. Eight of the 94 self-inflicted deaths in 2003 were of foreign national prisoners.
  • Offence-type. Those who take their own lives in prison are more likely than the general prison population to be imprisoned for violence-related offences. The most common offence-type of those who died during 2003 was violence against the person—accounting for 29 per cent of self-inflicted deaths in that year.
  • Legal status. Although unsentenced prisoners account for less than 20 per cent of the prison population, they comprise the majority of self-inflicted deaths (54 per cent). While 43 of those who died in 2003 were sentenced (46 per cent), the remainder were either on remand (36), convicted but unsentenced (10), in prison awaiting further reports (2) or detainees (3).
  • Previous history of self-harm. The majority of prisoners who take their own lives were not considered at risk of self-harm or suicide at the time of their death. Prison Service statistics show that in 2003, just 27 of the 94 self-inflicted deaths (29 per cent) were subject to an open F2052SH or ACCT (mechanisms for caring for those at risk of suicide or self-harm) at the time of their death.[38] Of those prisoners who were not considered to be at risk of suicide or self-harm at the time of their death, 62 per cent had also not previously been considered to be at risk during their current time in custody. However, in 8 cases a previous F2052SH had been closed within 4 weeks of their death, and in a further 12 cases it had been closed between 1 and 6 months before their death.
  • Length of detention. A consistent finding is that the majority of prisoners who die have been in the establishment for relatively short periods at the time of their death. Just under half (46 per cent) of prisoners who died in 2003 spent less than a month in custody (down from 54 per cent in 2002 and 52 per cent in 2001). In all, one in four prisoners who took their own lives had spent less than a week in the establishment at the time of their death.
  • Type of prison. In 2003, as in previous years, the majority of self-inflicted deaths (50 per cent) occurred in Category B Local prisons. This is consistent with the fact that newly sentenced and remand prisoners—who are largely held in local prisons—are most likely to take their own lives. It has been found that male local prisons that experience a self-inflicted death are statistically more likely to experience further deaths. In 2003, 49 establishments and one court experienced a self-inflicted death. Two prisons experienced five deaths and four prisons experienced four deaths.

52. The Prison Service does not collect information on whether prisoners who took their own lives had undergone or were undergoing at the time of their death mental health assessments, psychiatric treatment, drug or alcohol detoxification or drug and alcohol treatment. Similarly, no information is collected on how many prisoners who die in custody had a history of substance misuse prior to entering prison.

53. As part of the National Confidential Inquiry into Suicides and Homicides by Mentally Ill People, a study of prison suicides between 1999 and 2000 was published.[39] The study collected data held by the Prison Service's Safer Custody Group, and covered 172 suicides. Of these self-inflicted deaths, 72 per cent were of people who had one psychiatric diagnosis identified at reception. The most common diagnosis was drug dependency. In all, 32 per cent had a second diagnosis of a mental health problem, indicating more complex treatment needs. Over half (53 per cent) had a history of self-harm, 57 per cent had symptoms of psychiatric disturbance on reception to prison, and, of these, 72 per cent were referred to a healthcare professional in prison. Thirty per cent of people who took their own lives had a history of contact with NHS mental health services. One in six self-inflicted deaths (17 per cent) were among inpatients in the prison healthcare centre at the time of death, and 15 per cent of suicides were seen by health staff as preventable with closer supervision, better training and an increased use of shared cells. Respondents also indicated that a higher percentage of suicides could have been made less likely with closer supervision, better staff training in risk assessment, placement in a double cell or with a Listener, an increase in staff numbers, better ongoing support and clinical management, and better communication.

54. The statistics revealed in the above report are extremely concerning. The evidence demonstrates a clear link between drug dependency, mental illness, length of stay in prison and an increased risk of self-inflicted death. This highlights the areas where the Government must act if it is to meet the duty of care it owes to the most vulnerable people in its custody. Presently, however, it is clear that the Government is failing many of these people, leading to an unacceptably high level of self-inflicted death.

55. Moreover, the sheer numbers of people in custody with mental health problems and/or drug and alcohol dependency once again calls into question whether these people should be sent to prison in the first place—an environment that does not best address their medical needs and the likely causes of their criminal behaviour.

56. We recommend that the Prison Service should routinely collect information on whether prisoners who take their own lives, or attempt to, had received mental health or substance misuse treatment before or during their imprisonment. This would be invaluable in shedding more light on the broader circumstances of self-inflicted deaths in prisons and would highlight ways better to fulfil the Service's duty of care to prisoners and uphold their right to life.


57. There is no agreed definition within prisons of what constitutes "attempted suicide". Data recording incidents of "attempted suicide" are effectively subsumed within those for self-harm, which covers all reported acts of self-injury, however serious.

58. However, information is available on the number of resuscitations that took place. In 2003, 211 prisoners were successfully resuscitated by staff following serious self-harm incidents. Of these, over half (126) were women—a strikingly high figure when it is borne in mind that women make up such a small proportion of the prison population.

59. In 2003, there were a total of 16,223 recorded incidents of self-harm in prisons in England and Wales.[40] Many of these are likely to be accounted for by some individuals repeatedly self-harming—separate data is not available on the number of individuals who self-harm as opposed to self-harm incidents. However, these figures are likely to significantly underestimate the true extent of self-harm as they only include instances which come to the attention of the prison authorities and which are then recorded.


60. As noted above, self-harm is a particular problem amongst women prisoners—largely due to the significant and often imported vulnerability of many women in custody. In 2003, 30 per cent of women prisoners harmed themselves, compared with 6 per cent of men. At New Hall women's prison in Yorkshire, 100 of the jail's 365 prisoners were considered at risk of self-harm or suicide and had been made subject to the "Self-Harm At Risk Form" F2052SH procedures as of April 2004.[41] On our visit to Holloway, we were told that of Holloway's 444 prisoners at the time, 57 were at risk of suicide, and 8 women were on 24 hour watch. The evidence which we heard, supported by our visit to Holloway, indicates that women prisoners are placed at special risk. Not only do a disproportionate number of women self-harm in custody, we were told that several women are cut down from ligatures almost every night in Holloway Prison alone.

61. Moreover, there is a confluence of six factors that combine to put women prisoners at especial risk in the first few hours of being placed in custody.

  • Women prisoners are often especially vulnerable in any event—not only having mental health or drug dependency problems, but also being the victims of abuse—physical and sexual.
  • Many women prisoners are mothers, and have been taken away from their children—of itself a traumatising factor.
  • For the following reasons, women prisoners often arrive at prison very late in the evening—
    • There are so few women's prisons that they often have to travel longer distances from court to custody in any event;
    • In addition, there is a financial incentive to those responsible for transferring prisoners into custody to deliver men to prison before women.
  • It is only when they arrive at prison late at night that some are even asked whether they have dependent children at home or whether they are being looked after, leading to yet further maternal anxiety.
  • Many of the women prisoners that we met were sentenced—
    • for very short periods of time—often a week or less,
    • for very minor offences—for example, stealing coffee to sell to neighbours to buy drugs, and
    • very frequently—four or five times a year,
    • meaning that their lives and families were disrupted in this way repeatedly, and yet without any realistic chance of addressing the causes of their criminality.
  • The very design of women's prisons can exacerbate the risk of self-harm or suicide of these especially vulnerable prisoners. Holloway—for example—is designed as a hospital, making it especially difficult for prison officers to observe the women in their custody.


62. Homicides in prisons in England and Wales are rare—an undoubtedly impressive achievement given the relative freedom of movement that the vast majority of prisoners have within a prison, the inherently claustrophobic and pressure-cooker existence of prison life and the violent offence profile of many prisoners.

63. However, whilst rare, homicides do still happen in our prisons. There was one homicide in 2003. The death of Zahid Mubarek, killed by his mentally-ill cellmate Robert Stewart at Feltham Young Offender Institution in March 2000, was the subject of an inquiry by the Commission for Racial Equality which found 20 areas of failure in the management systems at Feltham either to identify the violent and racist nature of Robert Stewart or to protect Zahid Mubarek from him. A further independent inquiry into Zahid Mubarek's death has now begun.[42]

64. The Home Office has recently published research on homicides in prisons in England and Wales.[43] Amongst the report's main findings were—

  • There was an average of two homicides per year in the period 1990 to 2001 (26 in general)
  • Two-thirds of the homicides occurred in high security or local prisons
  • Twelve victims were in shared cells and 11 had been killed by their cellmate
  • Victims were likely to be young, white, male repeat offenders, serving sentences for violence, robbery or drugs offences, and sharing a cell.

The Prison Service has a strategy of using shared accommodation in their strategy for caring for prisoners at risk of self-harming. However, the finding that almost one-half of prisoners who were killed died at the hands of their cellmate suggests that this policy may need to be implemented more carefully.

65. Each year there are many other serious violent assaults which do not result in death. The Prison Service has recently introduced a new measure of violence towards prisoners, based on the number of reported serious assaults. Between April and December 2003, there were 611 serious prisoner-on-prisoner assaults.[44]


66. Between 1996 and 2003 there were no deaths in prisons through the use of control and restraint techniques. However, on 19 April 2004, 15-year-old Gareth Myatt died after losing consciousness while being restrained by staff at Rainsbrook Secure Training Centre.


67. In 2003, there were 76 deaths of prisoners through "natural causes". While the overwhelming majority of these were undoubtedly completely unrelated to the person's imprisonment, the standard of prison healthcare has attracted major criticism from, amongst others, NGOs, Independent Monitoring Boards (formerly Boards of Visitors) and the Prisons Inspectorate.[45]


68. There is considerable variation across Europe in levels of deaths in penal institutions. Latest figures for deaths in custody in 2002 from the Council of Europe show that the mortality rate in prisons in England and Wales was 23.3 per 10,000 prisoners and the suicide rate was 13.2 per 10,000. England and Wales had the joint ninth highest suicide rate amongst the 46 Council of Europe Member States.[46] However, a note of caution should be added when trying to make international comparisons of this kind, because of the risk that definitions may vary from one country to another.


69. The Prison Service has placed a great deal of emphasis in recent years on trying to reduce deaths in custody. When he was Director General of the Prison Service Martin Narey, now Chief Executive of the National Offender Management Service, announced that preventing deaths in custody was his top priority. This sentiment was echoed by the Prison Service's current Director General Phil Wheatley who told us that suicide prevention "is an important priority and something that is crucial for the service if we are to deliver a humane and decent service".[47]

70. A proactive three-year programme to develop policies and practices to reduce self-inflicted deaths in prisons began in April 2001. The programme included improvements in reception and induction arrangements, better inter-agency information exchange, changes in detoxification facilities, changes in procedures for identifying and managing prisoners at risk, the training and appointment of suicide prevention coordinators in the majority of prisons, the increased provision of prisoner-peer support, an investment of £21 million in six "Safer Local" prisons (Feltham, Leeds, Wandsworth, Winchester, Eastwood Park and Birmingham) and projects to develop safer prison design, including safer cells.

71. On 31 March 2004 a new outline suicide prevention strategy was announced to apply across all types of prisons and to all prisoners. In addition, women prisoners are to benefit from a specifically targeted and separate suicide prevention and self-harm management strategy being developed for them. This builds upon a number of interventions including: individual crisis counselling for women prisoners who self-harm; the continued development and evaluation of Dialectic Behaviour Therapy, which is currently being trialled at Durham, Bulwood Hall and Holloway prisons; investment and planning to ensure progress on the detoxification strategy in women's prisons; and the introduction of a new training pack for all staff working with women in custody. In addition, £1 million from the Department of Health is being spent on the recruitment of psychiatric nurses in women's prisons.[48]

72. We welcome the introduction of this scheme on a trial basis. If it is proven to be effective we strongly urge the Government to extend it nationwide as quickly as possible. In particular we welcome the individual crisis counselling for women and programmes specifically targeted at women. We recommend further analysis of the experiences of women and in particular reasons why they have a far greater tendency to self-harm than men. The individualisation of the treatment process and drawing up of specific courses of action concerning specific groups of people is a welcome step towards helping meet the positive obligations of a duty of care imposed by Article 2.


73. Deaths in custody of children and young people are especially distressing, and we therefore highlight them for specific comment. The Youth Justice Board has implemented a number of practical measures to minimise the risk of self harm and suicide among children in custody. These measures include the provision of safer cells, funding for 24 hour healthcare in all establishments that take young people, the provision of 'First night" packs for all young people entering custody, the commissioning of a regular survey of all young people in Young Offender Institutions (YOIs) and the commissioning of advocacy services for young people in prisons.[49] Nevertheless, there have been some deeply worrying cases of children and young people who have died while in the care of the state. Between 1990 and August 4 2004, 25 children have taken their own lives in prison and 2 children have died in secure training centres. An especially worrying case is that of Joseph Scholes, who hanged himself from the bars of his cell in Stoke Heath Young Offender Institution in March 2002 at the age of just 16. The death of Joseph Scholes highlights successive failures within the criminal justice system in meeting the needs of a highly vulnerable child.

74. At the time of his arrest for involvement in a series of robberies—albeit peripherally—Joseph Scholes was depressed, had begun to self-harm and have periodic suicidal thoughts. Two weeks before his court appearance, he slashed his face with a knife over 30 times. Prior to sentencing, the trial judge was alerted to Joseph's vulnerability, his experience of sexual abuse and history of suicidal and self-harming behaviour. Despite this he was sentenced to a two-year detention and training order, although the judge stated that he wanted the warnings about Joseph's self-harming and history of sexual abuse "most expressly drawn to the attention of the authorities." Nevertheless, Joseph Scholes was placed in prison service custody rather than local authority secure accommodation. Just nine days into his time at Stoke Heath Joseph Scholes hanged himself from a sheet tied to the bars of the window in his cell, where he had been kept in virtual seclusion.[50]

75. The inquest jury returned a verdict of "accidental death in part contributed to because the risk was not properly recognised and appropriate precautions were not taken to prevent it".[51] The coroner who presided over the inquest wrote to the Home Secretary calling for a public inquiry to be held. This is a call that we support. There has never been a public inquiry into the death of a child in custody. We recommend that the Home Secretary order a public inquiry into the death of Joseph Scholes in order that lessons can be fully learnt from the circumstances that led up to his tragic death. We also recommend that local authority secure accommodation should be used wherever possible for children, with use of prison service custody reduced to an absolute minimum.

76. In light of this disturbing case we would also like to draw attention to the recent comments of Jaap Doek, the Chairman of the UN Committee on the Rights of the Child, regarding the unnecessary jailing of juveniles in the UK.[52] His comments were made in light of the death of two children in custody this year. He also highlighted the recent report from the Children's Rights Alliance which voices concern at the under-funding of community support projects for teenagers, the imprisonment of child asylum-seekers and the disproportionate number of black people in prison. When addressing the custodial care of children it is extremely important to bear in mind Article 3 of the Convention on the Rights of the Child—to which the UK is a signatory—in which any action of the state regarding children must always have the best interest of the child at its core. This raises the crucial question of to what extent imprisonment can ever be deemed to be in the best interests of the child.

Police Custody

77. Home Office figures show that, between April 2003 and March 2004, there were 38 deaths in police custody in England and Wales, of which 7 were in police stations, 22 were in hospital, and the remainder were at the scene of arrest or following arrest.[53] None of the deaths at police stations involved the use of restraint, although six of those who died in hospital had been restrained by the police shortly prior to death.[54] All of those who died at police stations were white; one of those who died in hospital having earlier been restrained was black. In 2002-03, there were 8 deaths in police custody in Scotland.[55] In 2001, there were 5 deaths in police custody in Northern Ireland.[56]

78. A research study by the Police Complaints Authority (PCA)[57] illustrates the extreme vulnerability of those who die in police custody. The PCA found that, in the period between 1998-2003, there was an over-representation of ethnic minorities in deaths in police custody (17.6% of those who died were non-white, compared with 9% of the general population, and 13% of arrestees). The study also found that there were restraint issues in a higher proportion of the deaths involving non-white individuals (21.7%) than among white individuals (12.3%).

79. There are very high rates of drug and alcohol dependency, and of mental illness, amongst those held in police custody, and those who die there. The PCA's research[58] found that, of 153 deaths in police custody (including deaths in police custody suites, police vans, in hospital or in a public place following arrest) between 1998 and 2003, 43.8% had consumed alcohol prior to arrest, 17.6% cocaine; 12.4% heroin; 20.3% benzodiazepines; 8.5% ecstasy; and 13.7% cannabis. "Toxicity" was cited as a cause of death in 31.8% of the cases.

80. The PCA survey found that just over half of those who died had prior indications of mental health problems. Three of the 60 deaths surveyed by the PCA were of persons detained to be brought to a place of safety under section 136 of the Mental Health Act 1983.


81. A number of initiatives have sought to address problems related to deaths in police custody. The Standing Committee on Learning the Lessons from Adverse Incidents was established by the Home Office under the Chairmanship of ACPO in 2002. It reviews "adverse incidents" including deaths or injuries in police custody, and makes recommendations arising from this review. Its work resulted in guidance on the physical characteristics of police cells.[59] The National Custody Forum, together with the National Centre for Policing Excellence, is working towards developing practice to ensure safer detention in police cells.[60] The Metropolitan Police Service under its Professional Standards Directorate has established a Deaths in Custody Group dedicated to prevention and reduction of death following police contact.[61] These valuable initiatives appear to be limited to some extent, however, by the decentralised policing system, and by the wide variation in practice between police forces.

Immigration Detention

82. Although levels of deaths in immigration detention have historically been low, there is now increased resort to detention (from 250 places in immigration detention a decade ago to between 1,500 and 2,000 currently). Those detained are likely to be highly vulnerable, with high rates of mental illness and distress, and sometimes with past experience of imprisonment, ill-treatment or torture.[62] We are concerned that there appears to be a recent increase in deaths in immigration detention. The Home Office records 5 deaths in immigration removal (previously detention) centres between 1989 and mid-2003, 4 of which were self-inflicted.[63] In 2004, three apparently self-inflicted deaths have so far been recorded. In July 2004, a disturbance at Harmondsworth immigration removal centre was triggered when a detainee was found hanged.[64] A second detainee was found hanged at Dungavel removal centre a few days later, having been transferred from Harmondsworth after the disturbance.[65] An immigration detainee died in hospital following a suicide attempt at Colnbrook Immigration Removal Centre in November.[66] A fourth death of a detainee at Haslar removal centre, apparently from natural causes, was followed by allegations that he had been ill-treated at another immigration centre in the days before his death.[67] Evidence we have received from NGOs reports numerous incidents of self-harm in immigration detention. There were two deaths of immigration detainees in prison in 2002, two in 2003, and none in the first 11 months of 2004.[68]

Mental Health Act detention

83. The last comprehensive statistical survey undertaken by the Mental Health Act Commission, for the period between 1997 and 2000,[69] shows that in that period there were 233 deaths from unnatural causes of people detained under the Act.[70] Its evidence notes that the majority of these deaths were suicides, and that four deaths were directly related to the use of control and restraint powers, whilst 22 of those who died had been subjected to control and restraint in the previous week.

84. The most recent outline figures provided by the Mental Health Act Commission show that there were 304 deaths of detained patients in 2003. In 9 of these cases, control or restraint had been used in the 7 days preceding the death. In one case, restraint had been used within 24 hours of the death.[71] The MHAC estimated that one patient per annum over the last seven years had died whilst under restraint. [72]

85. INQUEST was concerned that some deaths where use of restraint was implicated might be inaccurately recorded as deaths by natural causes. The Chief Executive of the Mental Health Act Commission told us—

    We do not have really good data on any of this area. The Commission's collation of these statistics began essentially because no one else was doing it and it is quite possible that data collection might be improved in the coming years … I cannot be too sanguine that we know that all either natural deaths or unnatural deaths which apparently do not feature control and restraint did not, in fact, feature control and restraint because the data quality is not as good as we would want.[73]

86. The Report into the Death of David Bennett found that the lack of sufficient statistics made it difficult to draw general conclusions on deaths in psychiatric hospitals. It recommended that more detailed statistics should be kept, to enable analysis of how many detained patients died under restraint or shortly thereafter, and on how many such patients were from an ethnic minority.[74] Following this recommendation, the Director of Mental Health for the Department of Health has been made responsible for the collection of these data as part of the Confidential Inquiry into homicides and suicides by the mentally ill. We recommend that annual statistics should be published by the Department of Health, recording the numbers of natural and self-inflicted deaths, homicides and deaths which are restraint-related, as well as attempted suicides, and detailing the age, gender and ethnicity of those who died or attempted suicide.

31   First Report of Session 2003-04, Deaths in Custody: Interim Report, HL Paper 12, HC 134, Ev 26 Back

32   Figures for the first 11 months of 2004 are 94 self-inflicted deaths in prisons  Back

33   HL Deb, 3 February 2004, col. 94WA. 3 Coroners' verdicts were being waited on for 2003, 1 in 2001 and 1 in 2000. Back

34   Q 322 Back

35   Ev 185 Back

36   ibid Back

37   These figures are from HM Prison Service, see Ev 104-106  Back

38   F2052SH is the Prison Service Self-Harm At Risk Form. Prisoners with an 'open' F2052SH are considered to be at risk of self harm Back

39   J Shaw, L Appleby and D Baker, Safer Prisons: A National Study of Prison Suicides 1999-2000, The National Confidential Inquiry into Suicides and Homicides by People with Mental Illness, May 2003 Back

40   HC Deb., 5 May 2004, col. 1549W Back

41   HC Deb., 8 June 2004, col. 327W Back

42   The inquiry, chaired by Mr Justice Keith, began hearing evidence in November 2004.It was established following the ruling of the House of Lords (in ex parte Amin, op cit) that previous investigations of the case did not satisfy the Article 2 ECHR right to a full independent inquiry.  Back

43   G Sattar, 2004, Prisoner-on-prisoner homicide in England and Wales, Home Office Findings 250 Back

44   HC Deb., 10 February 2004, col. 1435W Back

45   See Chapter 6 Physical Healthcare and Chapter 7 Mental Healthcare Back

46   M Aebi, Space I, Council of Europe Annual Penal Statistics, Survey 2003, Strasbourg, 17 May 2004 Back

47   Q 324 Back

48   HC Deb., 8 June 2004, col. 328W Back

49   Ev 130-131  Back

50   INQUEST, Why are children dying in custody?, November 2004 Back

51   ibid Back

52   Britain violates rights of child say UN, The Guardian, 29 November 2004 Back

53   Home Office, Deaths During or Following Police Contact, Statistics for England and Wales April 2003 to March 2004 Back

54   Inquest verdicts are still awaited in a number of the cases recorded Back

55   Response by the UK to issues raised by the United Nations Committee Against Torture for Discussion at the Committee's 33rd Session in November 2004, Appendix 2 Back

56   ibid., Appendix 4 Back

57   See our First Report of Session 2003-04, Deaths in Custody: Interim Report, HL Paper 12, HC 134, Ev 64 Back

58   ibid., Ev 60 Back

59   Home Office Circular 18/2002 Back

60   Q 406 Back

61   First Report of Session 2003-04, op cit., Ev 11-14 Back

62   First Report of 2003-04, Deaths in Custody: Interim Report, HL Paper 12, HC 134, Ev 68-73 and Ev 106-107 Back

63   Ev 14 Back

64   Riot at fast-track asylum removal centre, The Guardian, 21 July 2004 Back

65   Harmit Athwal, Institute of Race Relations, Death Trap: the Human cost of the war on asylum, 2004 Back

66   Kenny Peter died on 4 November 2004 Back

67   Harmit Athwal, op cit Back

68   ibid. On the detention of immigration detainees in prison see para. 128 below  Back

69   Mental Health Act Commission, 2001, Deaths of Detained patients in England and Wales; a report by the Mental Health Act Commission on information collected from 1 February 1997 to 31 January 2000.See our First Report of Session 2003-04, op cit., Ev 37-46  Back

70   Only one third of these deaths occurred whilst actually in detention; the remainder occurred whilst absent from the place of detention, or in a general hospital. The Commission collated these figures according to the cause of death determined at inquests. Back

71   Ev 120 Back

72   Q 169 Back

73   Q 170 Back

74   Norfolk, Suffolk and Cambridgeshire Strategic Health Authority, Independent inquiry into the death of David Bennett, December 2003, page 63 Back

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