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Baroness Neuberger: My Lords, I am sure that I speak for all Members of your Lordships' House when I congratulate the noble Lord, Lord Ramsbotham, on a superb maiden speech. It was moving, profound and impressive and I hope that much of what he said will be taken up by the Government and that the Minister will respond to it.

The noble Lord, Lord Ramsbotham, had an immensely distinguished military career and made an extraordinary contribution as Her Majesty's Chief Inspector of Prisons. Noble Lords will remember the wonderful moment when he called off the inspection of Holloway prison because conditions were just too awful. The noble Lord has been brave, consistent and, for many years, has pointed out to us what we can do to improve conditions in our prisons and to stop the appalling rate of deaths in custody in our country. I am sure that what he has said today is just a taste of things to come.

I too wish to congratulate the noble Baroness, Lady Stern, on initiating this debate in the wake of the Joint Committee's excellent and very disturbing report which I spent much of our recent Recess reading. My interest in deaths in custody comes largely from my interest in mental health in prisons.

I have several interests to declare. I am a former chief executive of the King's Fund and an adviser to the trustees of the Sainsbury Centre for Mental Health.

In my time chairing an NHS trust in central London—Camden and Islington Community Health Services NHS Trust—I was involved in a variety of diversion schemes away from prison into the mental health system. We also carried out an experiment with prison link workers run by the Revolving Doors Agency to see whether link workers could make a difference by getting those in custody to get practical support from police, health, social and housing services. That was to ensure that they were in touch with local services as they went into custody—and,
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most importantly, when they came out—and to play an advisory and supportive role for up to two years, mostly after release.

The evaluation published in 2003 funded by the King's Fund, of which I was then chief executive, demonstrated a major improvement in the health of those who had link workers attached to them. Thirty-six per cent of the clients had GP mental health assessments and relevant treatment; 29 per cent of all clients were provided with services for drug addiction and alcohol issues; and 15 per cent of the clients still in prison were referred to drug services by the link workers.

Why do I raise that in this debate? I raise it because in most of the cases of deaths in custody that we know about the prisoners had no such links. Most had no link worker staying with them from the time of arrest and most were in real despair, disorientated, terrified, vulnerable and alone and many had diagnosable mental illness to boot. Their basic rights to proper care were ignored or compromised.

The most recent Prison Reform Trust set of statistics—I am immensely grateful to the trust and to Inquest for the help that they have given to many noble Lords, I suspect, for this debate—tells us that the number of women in prison has more than doubled over the past 10 years. There has been a very slight decline over the past 12 months, but what is terrifying—the noble Lord, Lord Judd, has already mentioned this—is that 14 per cent of suicides in prison in 2004 were committed by women when they make up only 6 per cent of the prison population.

Most women are held for non-violent offences and the largest proportion is held for drug offences. To add to that, women in prison suffer from several mental health problems; two-thirds of them show symptoms of at least one neurotic disorder—depression, anxiety or phobias; more than half suffer from a personality disorder and half are on prescribed medications such as antidepressants or antipsychotics. The use of medication increases while they are in custody.

To add to that, of all women sent to prison, 37 per cent say that they have attempted suicide at some time in their lives, while the incidence of self-harm is far greater among women than among men—some 30 per cent compared with 6 per cent for men. On average, each woman who injures herself does so five times compared with twice for men. Although women make up only 6 per cent of the prison population, they account for nearly half of all reported self-harm incidents. Meanwhile nearly two-thirds of them have a drug problem.

The noble Baroness, Lady Stern, has already raised the issue of young prisoners who are equally at risk, if not more so. We have debated in your Lordships' House the issue of Joseph Scholes and his tragic death. We can add to him Gareth Myatt, who died in Rainsbrook secure training centre after being restrained by three adult staff members. The lack of a homicide investigation into that death bears close examination as the restraint technique being used was called into question by the police when investigating
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his death. There was also Adam Rickwood, aged 14, who hanged himself at Hassockfield STC. There have been others, vulnerable children and young people who are known to self-harm, who nevertheless have killed themselves or who have died while in our care.

Yet we seem to do very little about it. The number of 15 to 17 year-olds in prison has nearly doubled; and 28 children have died in penal custody since 1990, most by suicide but one following restraint.

Only one quarter of children in prison at the end of March this year had been convicted of violent offences. Many, as we know, have a background of severe social exclusion, and of those of school age a quarter have literacy and numeracy levels of an average seven year-old.

In the next group, the 16 to 20 year-olds, 85 per cent have a personality disorder; 10 per cent have a diagnosable psychotic condition such as schizophrenia; and the drug and alcohol dependencies are high. One could go on.

That raises huge issues for us. I ask the Minister to answer some of the questions raised by other noble Lords but also the specific issues around restraint techniques after the deaths of Adam Rickwood and Rocky Bennett, who was detained under the Mental Health Act at the Norvic centre. He died while apparently being restrained by five people.

Secondly, now that the NHS is at last providing health services in prisons, what can be done to improve the level of service that the NHS can provide, particularly in mental health? Prisoners are twice as likely to be refused treatment for mental health problems inside as they were outside.

Thirdly, what can be done to make adequate secure provision available? In the Gorsuch study it was clear that when 114 women for Holloway were referred to secure hospitals half were turned down. Those who were rejected were more likely to have harmed themselves, suffered childhood abuse, committed serious offences or been violent or dangerous than those who were accepted by the secure hospitals. Surely, that is not a sensible way to run our services.

Fourthly, what can be done to support prisoners when they come out? Immediately on release 75 per cent of them have no outside carers and the suicide rate on release is very high. Every year more than 50 prisoners commit suicide shortly after release. We know that link workers will make a difference in that area.

Lastly, I echo what the noble Lord, Lord Ramsbotham, said about the United States and argue that we could learn from the wonderful examples, particularly of organisations such as CASES or Family Justice where experienced, very skilled and highly qualified workers work with the most difficult prisoners and people who are detained but perhaps in hospital or in the community with great support. They do not tend to go down the line we go down in Britain with understaffing and where junior staff without adequate experience and support are given the task of looking after the most troubled and vulnerable prisoners.
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Baroness Murphy: My Lords, I first add my welcome and congratulations to the noble Lord, Lord Ramsbotham, on his very powerful address. He will certainly be an asset in this House in this area and, I am sure, in many others. I also congratulate the Joint Committee on its very powerful report.

I want to take noble Lords back to what Mr Blunkett said. He said:

Yes, Mr Blunkett, you do.

Are the then Home Secretary's personal thoughts on the suicide of a multiple murderer of any relevance to this debate? I think they are, but before I wax on that point I should point out that I, like most, psychiatrists, have been clinically responsible for someone who died while detained under the Mental Health Act while in my care.

I remember well the last time. It was the case of a sick old man who slumped into a psychotic, deluded depression after the death of his wife and his subsequent unwanted admission to residential care. He was admitted compulsorily to our acute unit because he did not want to come; he wanted to stay at home and die. He seemed to be doing very well and picking up after the treatment. One afternoon we discussed his going back to the care home soon and coming in daily to see how he was getting on.

At 6 o'clock the next morning, he walked out of the ward, which was not locked, to his old home area and by 7 am he had thrown himself under a bus. I sat through the coroner's inquest and remember the distress of the bus driver, who had seen him coming towards him. Afterwards, the man's daughter said to me, "But we thought that he would be safe with you". The subsequent internal inquiry revealed a catalogue of simple errors—some of which, of course, were mine—but I hope that we put right the problems in our unit for future people of that description.

What is it that connects Shipman and my patient with the difficult, despairing and often violent prisoners who so often figure in suicides and unexpected deaths in custody? I have now served on a number of public and private inquiries into serious and untoward incidents at special hospitals and closed psychiatric units of patients who were held in seclusion and those who were not. The Minister will well recall one year of both our lives given to one very public inquiry in Liverpool into the events at Ashworth Hospital. Since then, I have had much more experience of inquiries—in fact, so much experience that I have given up doing them, because I can now write the findings without hearing the evidence.

All the findings are broadly the same. First, risk assessment is always poorly understood and either inadequately done or done by someone so inexperienced or ill-trained that it is meaningless. Secondly, crucial written or telephone information about previous behaviour is unrecorded by the institution; is buried
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beneath a pile of irrelevant information; or is not available out of hours, when the people who are caring for the person need it. Thirdly, the best information is available from relatives, close friends of the individual or fellow inmates, but no one has listened to them. No one has even thought to ask. In the case of offender institutions, there is often no way of conveying that information to anyone who seems to care.

So often, relatives say, "We knew he was going to do it because he said so". Regrettably, in some institutions, staff attitudes are still a major problem. We have heard much praise today for the work that prison officers and police caring for people in custody do, and I have no doubt that that is right. But, I fear, staff who are responsible for observing a potentially suicidal person do not always consider it important if the person dies. They feel about their charges like Mr Blunkett felt about his: they do not feel that those individuals matter that much.

How often have I heard at a coroner's inquest someone ask a prison officer, "How often was someone being observed?" The officer replies, "Oh, he was being observed every 15 minutes". That may be true, but was there a listening ear or a kind word offered at a crucial moment? Probably not. Alternatively, in psychiatric units, there is so often an attitude of completely mistaken liberalism: "Well, it's his decision, innit? They're free to come and go now; we leave it to people to make their own decisions about whether they stay or go". Both those attitudes override the primary duty of care.

I do not know how common those attitudes are in prisons, but if the man in charge did not understand his duty to protect the lives of those in care, what chance for the prison officer working in some remote gaol? The emotional environment in which prisoners are contained is, in my view, bound to lead to deaths, as it does at present. We have heard about the physical isolation and design, of what can be unfriendly close surveillance and of means of suicide unwittingly made available. Those are important, but not the most important. The question is: can attitudes and risk assessment be improved with training? Yes, of course, but that will work only if governors, senior officers and senior police officers provide the role models that truly change attitudes.

Finally, I comment on the obvious. The populations of prisons and psychiatric institutions overlap to such an extent that it sometimes feels pretty random in which one a troubled individual ends up. Many folk have experience of both. Sometimes I think that it depends on which estate you grow up and on how early you started drugs. The official line from everyone is that of course we must get seriously mentally ill people out of prison and into mental health care. That is absolutely true, but it is not happening very fast. There are not the resources from the health service and it will not provide a solution except to seriously psychotic prisoners. Two thirds of prisoners and young offenders have very marked psychiatric and mental health problems, emotional problems and personality difficulties. They simply will not get transferred. We must provide far better care in prisons and offender institutions.
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I strongly support the growth of NHS services but they are woefully inadequate. A registrar of mine at Guy's Hospital, on a scheme providing a placement for the assessment of prisoners going into Brixton, came back after his first day in a state of shock. He said, "Here we have on average an hour to make a first assessment of a patient in a hospital. I can spend as long as I want on the phone with relatives and get them in to see them quickly. I have five minutes to make an assessment of someone admitted to Brixton prison".

The resources are grossly inadequate and certainly need improving. But we must also transform our own attitudes to what a prison should be like and how it should function. As long as prisons remain a punitive, alienating place it will surely be difficult to eliminate those essentially avoidable deaths.

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