Joint Committee On Human Rights Third Report

5 Risk Assessment and Management

131. The imprisonment of large numbers of highly vulnerable people is a reality of the present system which places a significant burden on institutions of detention to assess and respond to the risks that detainees pose to themselves or others. As we have mentioned previously, this is an extremely unsatisfactory situation. However, basic steps are needed in order to limit the risk to those vulnerable people in custody. Accurate and informed risk assessment at the time a person first enters custody, or is transferred from one custodial institution to another, is essential for the management of the risk that that person may commit or attempt suicide. With such a large proportion of prisoners who take their own lives doing so within their first few days or weeks in prison, it is essential that appropriate and comprehensive reception and induction arrangements are in place to identify any health or support needs that prisoners have, and to make the transition to imprisonment, or the move to a new prison, less disturbing. Effective information exchange, in accordance with privacy rights, between the police, prison, immigration service and health services, on the vulnerability of a detainee to suicide or mental illness, or the threat which he or she may pose to others, is also crucial to establishing an individual approach to detainee care in accordance with the positive obligations under Article 2.[111]

132. Therefore, in our analysis of the problems which authorities face in minimising deaths in custody, and the strategies which they may use to this end, we deal first with the question of risk assessment and management.

Prison reception, induction and assessment arrangements

133. Currently, guidance requires prisons, generally with the prisoner's consent, to request any information required from a prisoner's general practitioner or other relevant service with which the prisoner has recently been in contact. It also sets out the circumstances in which information may be requested and disclosed without consent. We wish to highlight the importance of prisons obtaining medical records about a prisoner's mental and physical health from clinicians who have provided treatment prior to imprisonment and to ensure that this is monitored rigorously by Prison Service headquarters.

134. This is all the more important because at present - according to MIND and a number of other witnesses—prisons are not always aware of someone's mental health needs on reception. This appears to be part of a wider, though not universal, problem about the comprehensiveness and quality of the information available to prisons on reception. The situation appears to have been compounded by the fact that overcrowding has led to prisoners frequently being moved around the prison system at very short notice.[112] It is essential that all new arrivals to a prison are properly assessed by fully trained staff for mental and physical health problems and for any risk of self-harm or suicide. This assessment would be a great step towards helping the Prison Service adequately provide the duty of care prescribed under Article 2.

135. The problem appears to be particularly acute in women's prisons. At Holloway prison we were told that it was common for prisoners to arrive at reception very late at night, often accompanied by only very poor information on their health and circumstances. Often it was only at a late hour that it was discovered that the prisoner's children were not being cared for. The problem was compounded by the fact that many of the women imprisoned at Holloway had had little prior contact with services in the community, so information about their background was not easily accessible. Staff expressed great concern at the lack of information on new prisoners, and the difficulties this caused in managing risk, in particular since prisoners at Holloway tended to be highly distressed and at risk.

136. Also at Holloway, medical staff found that the late reception of prisoners caused considerable problems for the service they sought to provide. On the day we visited, prison doctors had been assessing newly arrived prisoners until midnight the previous evening. It was pointed out that this placed considerable strain on prisoners as well as on medical staff. We consider it completely unacceptable, in the context of preventing deaths in custody, that new prisoners should arrive at prison reception too late to allow full assessment at a reasonable hour. It is essential that all new arrivals to a prison are properly assessed by fully trained staff for mental and physical health problems and for any risk of self-harm or suicide. Prisoners should arrive at prison accompanied by essential information on their state of physical and mental health and on their outside circumstances, and should arrive in good time for a full health check to be made at a reasonable hour on the first evening in custody.

137. During the evidence that we took—and our own prison visits—we were struck by the need to provide comprehensive support to prisoners in their very early hours and days in a prison. Many remand prisoners in particular may not have expected a custodial sentence and will need practical as well as emotional support to deal with the upheaval and distress caused by imprisonment.

138. The Prisoners Advice and Care Trust (PACT) runs a First Night in Custody project at Holloway Prison, which was set up in September 2000. The service's aim is to work with the most distressed women who come into Holloway Prison to spend their first night ever in custody. According to PACT, "the main objectives are the reduction of anxiety felt by this group, and to ensure that information about all the resources available to new prisoners, both inside and outside of the prison, is given at reception".[113]

139. The First Night in Custody project was proposed in response to a number of reviews, which highlighted the gaps in the service provision to women when they enter custody for the first time. In particular—as the Prisons Inspectorate report, 'Unjust Desserts' found—between a third and two-thirds of unsentenced prisoners had not expected to be sent to prison and so were especially vulnerable on reception.[114]

140. The First Night in Custody project at Holloway has been the subject of an evaluation by the Centre for Crime and Justice Studies at King's College, London. This found that—

  • 75 per cent of new receptions to the prison felt 'anxious' or 'worried'
  • 65 per cent were 'very concerned' about notifying their family of their whereabouts
  • Nearly half (47 per cent) of the women sampled had received previous treatment for depression
  • Half had a self-confessed problem with alcohol or drugs
  • 69 per cent feared losing their home as a result of imprisonment
  • It was acknowledged in all the interviews with reception staff and the various Governors and Heads of Department that the First Night in Custody project reduced the anxiety felt by people in prison for the first time.[115]

141. We commend the work done by first night in custody schemes and recommend that all prisons introduce similar schemes to support prisoners received into custody for the first time. We also recommend that new prisoner receptions should receive a minimum of a week of close observation and assessment in a dedicated area. This would provide prisoners with time to acclimatise to their new environment and would allow staff to carry out proper risk and health assessments.

142. There is also a need for ongoing assessment of prisoners—both in case mental health needs were overlooked during initial reception screening, and in case mental health problems develop during the course of someone's time in prison. In their evidence to us, the Revolving Doors Agency expressed concern about the extent of hidden mental health problems in prisons. They told us that there is a "clear reluctance" among inmates to be labelled mentally ill—which although it reflects the situation in the wider community, is likely to be intensified by the added stigma associated with having a mental health problem among the prison population. Revolving Doors stated that: "It is clear that bullying problems exist throughout the prison system and in many cases it will be those labelled mentally ill who are subjected to bullying. The persistence of such problems helps to create and sustain an environment in which inmates are unwilling to access services".[116] Prison staff must receive training in mental health awareness and should be alert to warning signs such as prisoners becoming withdrawn or aggressive and refer them to mental health in-reach teams if appropriate.

Reception in Police Custody

143. On reception in police custody suites, custody officers undertake an assessment of risk, which include questioning of detainees on their state of health or mental health. This assessment may form the basis for referral to a Forensic Medical Examiner (FME), also known as police surgeons. ACPO pointed out that there was a need for effective flow of information from the prison service to the police, as well as from police to prisons. They referred to a lack of procedures in this regard—

We recommend that provision should be made for exchange of information on suicide risk from prisons to the police in appropriate cases.

Immigration detention

144. Evidence suggests that provision of information has also been unsatisfactory in relation to those held in immigration removal centres, who may have particular healthcare or mental health needs, and in particular may have experienced torture or ill-treatment abroad.[118] We were provided with evidence of cases where immigration detention centre medical staff did not pass on medical information to the centre managers, contrary to the Detention Centre Rules[119] and Operating Standards. The Chief Inspector of Prisons has recommended that protocols should be agreed for the release of medical information, with consent, to the immigration authorities and detainees' representatives, if such information is relevant to fitness to detain or to the detainee's asylum claim, and for the action that should follow.[120]

145. The Home Office's written evidence to the inquiry states that "to the extent that it is possible to do so where very little may be known about the individuals concerned, the Immigration Service will, amongst other risks or special needs, identify whether a person who is being detained is likely to present a risk of suicide or self-harm and this information will be passed to the detaining agency".[121] The Detention Centre Operating Standards on Healthcare[122] require medical staff to report to the centre manager and the immigration service cases where a detainee's health is likely to be harmed by continued detention, or if a detainee has suicidal tendencies. In doing so, however, they are required to take account of medical confidentiality, unless the patient has given consent to disclosure of information.

146. Medical confidentiality is supported by the right to respect for private life under Article 8 ECHR. However, medical confidentiality should not prevent limited disclosure of information to detention centre managers, in order to protect a detainee's rights under Articles 2, 3 and 8, where a detainee may be at risk of suicide or self-harm. Information on the risk of suicide or self-harm should be used to inform decisions on whether an individual is detained in immigration detention, and how he or she is cared for in detention. We are concerned that, despite guidelines, this may not be happening effectively in practice.

Safer cells and surveillance

147. Evidence from all forms of detention cited problems related to the physical condition of detention facilities, in particular the existence of ligature points.[123] This was a particular problem where older, many 19th century, buildings continued to accommodate detainees. At Broadmoor for example, we visited one of the women's wards where patients at high risk of suicide were accommodated in 19th century buildings which retain ligature points, and which do not provide acceptable modern standards of accommodation for many seriously ill patients. The Mental Health Act Commission have suggested that "poor therapeutic conditions" including in some hospitals 200% bed-occupancy and an inappropriate mix of patients, may be a cause of self-harm or suicide.[124] Wards are often "substandard, frightening and even dangerous".[125] In November 2003, the Commission for Health Improvement[126] found that the majority of wards at Broadmoor were lacking in basic standards of dignity, privacy, cleanliness and amenities, and concluded that "the overwhelming majority of ward areas cannot be considered an appropriate, humane environment".[127] The Mental Health Act Commission has also raised concerns about the physical condition of high secure hospitals, and in particular has stated that it is "not possible to deliver a safe and therapeutic environment" within the older wings at Broadmoor hospital.[128] Sub-standard or unsafe conditions of detention may violate Article 3 ECHR, as well as Article 8. We recommend that funding should be made available to ensure that people at risk of self-harm or suicide are held in decent conditions of detention.

148. Research has consistently shown that if a given method of suicide is no longer available, although some displacement may take place, overall suicide levels fall. This has led to the Prison Service making use of situational suicide prevention strategies such as safer cells, where obvious ligature points are eliminated. Safer cells were first introduced in HMP Belmarsh in 1997 with the aim of reducing hanging. In a safer cell, all the corners are rounded, the pipes are covered, the light fittings are modified, and a safe ventilator is placed instead of windows that open and could therefore be used to attach a ligature. Programmes to remove ligature points and to provide "safer cells" are in place in the prison service, police forces, and in secure hospitals.[129] We were consistently told however, that much remains to be done to extend this programme to provide sufficient safe cells, and to deal with the many problems posed by holding detainees in older buildings. Measures were also being taken in many police forces to install CCTV in cells as a means of ensuring safety; but the high costs involved have meant that CCTV remains installed in only a small number of cells.[130]

149. A preliminary evaluation of the use of safer cells has been carried out by the Jill Dando Institute of Crime Science at University College London. This found that "safer cells were likely to be useful in preventing suicides if implemented correctly. For example, of the 27 at-risk prisoners who were interviewed, three spontaneously stated that they would have hanged themselves had they not been in a safer cell (one of them having tried and failed). Although some displacement took place, the evaluation found that these alternative methods such as cutting are less lethal and leave more time for staff intervention. It is therefore concerning that the evaluation found that "quite often there are not enough safer cells within the unit, and prisoners may have to be prioritised or moved to other locations in order to be in a safer cell".[131] We consider that safer cells should be widely available in all prisons and should be used to hold at-risk prisoners. However, they should be used alongside, and not as a substitute for, other suicide prevention strategies such as comprehensive mental health care, good staff-prisoner relationships, comprehensive risk assessments and provision of support through Psychology, the Samaritans or Listeners.

150. Suicide prevention is of course a much more complex matter than the removal of ligature points and the imposition of rigorous surveillance; and the safety of detainees is a matter not just of immediate suicide prevention, but of what is sometimes termed "relational security",[132] safety achieved through well-being and quality of life. It is important to note that the Article 2 positive obligation to protect life requires that reasonable measures be taken to protect detainees who are vulnerable to suicide. It does not require the authorities to impose absolute safety by draconian means. There are limits to the positive obligation to protect, which must also be balanced with other Convention rights which protect the quality of life of a detainee, in particular the right to respect for private life and personal autonomy (Article 8), and the right to respect for physical integrity and to freedom from inhuman or degrading treatment (Article 8, Article 3).[133] As the ECtHR stressed in Keenan v UK, protection of the Article 2 right to life must be conducted in a manner compatible with the other Convention rights of a detainee, and in particular the principle of personal autonomy.

151. A detention regime that respects a detainee's human rights, rights to respect for private life, alongside, and balanced with, measures to prevent suicides, is an important element in detainee safety. We recommend that strategies for suicide prevention in all forms of detention should take into account the need to respect the privacy and physical integrity of people in detention. Excessive focus on control, at the expense of detainees' well-being, will not prevent deaths in the long term, and will not assure compatibility with the Convention rights.

152. Nevertheless, we support moves to provide safe cells in prison and police custody, and to provide similarly safe accommodation in secure hospitals. It is a particular concern in relation to deaths in custody that detainees at known risk of suicide may be held in an environment which includes ligature points. We recommend that efforts should continue to provide safe accommodation in all forms of detention.

111   Edwards v UK (2002) 35 EHRR 19 Back

112   Q 340. And see Chapter 4 Prison Overcrowding and Sentencing Back

113   J King et al, 2002, Evaluation of the First Night in Custody Project HMP Holloway, PACT/CWS, London Back

114   HM Inspectorate of Prisons, Unjust Desserts, A Thematic Review by HM Chief Inspector of Prisons of the Treatment and Conditions for Unsentenced Prisoners in England and Wales, December 2000 Back

115   J King et al, 2002, Evaluation of the First Night in Custody Project HMP Holloway, PACT/CWS, London Back

116   Ev 183 Back

117   Ev 135 Back

118   See our First Report of Session 2003-04, op cit., Ev 106-107 and Ev 68-73  Back

119   Rule 35 of the Detention Centre Rules 2001 (S.I., 2001, No. 238) Back

120   Her Majesty's Chief Inspector of Prisons, Introduction and Summary: Inspection of Five Immigration Service Establishments, April 2003 Back

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

122   Her Majesty's Chief Inspector of Prisons, op cit., paras. 16 and 17 Back

123   Fixed points capable of bearing sufficient weight for a person to be able hang himself or herself from them. Back

124   First Report of Session 2003-04, op cit., Ev 38 Back

125   ibid., Ev 45 Back

126   Whose functions have now been taken over by the Health Commission Back

127   Commission for Health Improvement, Clinical Governance Review, West London Mental Health NHS Trust, November 2003, p. 29 Back

128   10th Biennial Report, 2001-03, para. 12.6 Back

129   The Department of Health has provided funding for, and issued targets on, removal of ligature points. See our First Report of Session 2003-04, op cit., Ev 18 and Ev 43 Back

130   Meeting with the Metropolitan Police Force. The MPS is aiming for 50% CCTV coverage in its cells. Back

131   Summers L, 2003, Reducing Self-Harm and Suicide in Prisons: Advice for Prison Staff on Using Safer Cells, Jill Dando Institute of Crime Science Back

132   First Report of Session 2003-04, op cit., Ev 46. Mental Health Act Commission quoting Kinsley: relational security "begins with the patient and is essentially concerned with detailed knowledge of the patients and their situation … it will extend to relationships and professional agencies outside the hospital, so that although the institutional boundaries are very definite, effective security can often have its roots in the community. The provision of education, rehabilitation and pastoral facilities as well as leisure and social activities all have an important part to play … ". We were impressed during our visit to Caswell Clinic medium-secure unit in Bridgend by the positive effect resulting from a culture of relational security embracing all these factors. Back

133   See Chapter 2 Human rights standards and deaths in custody Back

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