HMP Edinburgh | Thomas Nugent | CC |

Scottish prisons fail to protect inmates at risk of suicide


Scottish prisons have failed to protect vulnerable prisoners at risk of suicide due to a number of serious breaches of official policy, an investigation by The Ferret can reveal.

Failures to follow suicide risk management guidance have been factors in the deaths of at least 16 men and some families have been left waiting years for an official explanation from the authorities regarding the deaths of relatives in prison.

Major problems identified by The Ferret include serious communication breakdowns between courts and prisons, inadequate staff training and a failure by prison staff to follow procedures and properly record information.

There have been 129 deaths in Scottish prisons since 2007 including at least 34 suicides.

No official explanation has yet been given for 42 people found dead in prison during that period. One of the unexplained deaths occurred seven years ago.

All deaths in prison custody are subject to a Fatal Accident Inquiry (FAI) under the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976.

The Ferret examined 26 Fatal Accident Inquiries dating back to 2007 and found serious problems relating to 16 prison suicides.

The Scottish Prison Service’s (SPS) system for identifying prisoners at risk is called ACT2 Care which aims”to address risk of suicide and suicidal behaviour and promote a caring environment where those in distress can ask for help.”

However, prisons have failed to identify and protect a number of highly vulnerable prisoners at risk of suicide despite recommendations by sheriffs over the years to improve communication procedures.

In some cases families claimed their warnings to prisons that loved ones were suicidal were not properly acted upon.

During the FAI into the death of Richard Crompton who hanged himself in HMP Addiewell in January 2009 it emerged that prison staff had little experience of ACT2 Care procedures.

One officer gave evidence that she did not feel qualified to carry out a risk assessment and had received only one hour of training on mental health issues prior to the prison opening.
She told the inquiry she considered the training to be inadequate. Similarly, a mental health nurse told the FAI she received no formal training on ACT 2 Care procedures. The FAI said this was”a cause of some concern”.

In response, a Scottish Prison Service spokeswoman said:”The Scottish Prison Service takes all deaths in custody very seriously. The majority of individuals in our care come from the most deprived areas of Scotland, often with complex lifestyles which can include difficulties with substance misuse and mental health issues.

“We agree that one suicide in prison is one too many, and recognise the significant challenges our staff face in managing the many vulnerable individuals in our care.

“The SPS continues to invest heavily in training all staff and partners in ACT2Care. The importance of the strategy is re-emphasised with annual refresher courses to ensure competency and continued awareness.

“We always review in detail the recommendations of Fatal Accident Inquiries, and action is taken via the multi-agency National Suicide Risk Management Group to address any shortcomings highlighted by this process.

“Delivery of health services transferred from SPS to the NHS in 2011. However, prison staff are committed to working in partnership with health professionals, ensuring a shared responsibility for the care of those at risk of suicide or self-harm.

“Although we appreciate that it can take time to instigate and complete an FAI, the prison chaplaincy teams are always available to provide support to prisoners’ loved ones. We have also developed an information resource to aid families during this difficult time, in partnership with Families Outside.”

A spokesman for the Crown Office and Procurator Fiscal Service, said: “The 2007 death you refer to relates to John Heggarty, an absconded prisoner from Castle Huntly prison, near Dundee. He was discovered dead on 13 April 2007 on public waste ground near to a Fire station in Glasgow. He had escaped from prison custody some 9 days earlier. He did not die in Prison, and as such a mandatory FAI in terms of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976 was not required. No discretionary FAI was instructed as no issue of serious public concern arose in this death.

“COPFS ensures that FAIs are held as soon as practicable and most death investigations conclude once a cause of death is know. However others require further detailed and lengthy investigation, often involving complex technical and medical issues and expert opinion, to be carried out before we can proceed with a Fatal Accident Inquiry.

“Since April 2012 we have further strengthened the way we deal with deaths investigation. All non suspicious deaths reported to the Procurator Fiscal are investigated thoroughly and expeditiously by the dedicated specialists in the Scottish Fatalities Investigation Unit (SFIU).

“Throughout investigations SFIU will liaise with the nearest relatives of the deceased’s family to ensure that they are kept fully informed of any progress.”

Policy Failures in Suicide Risk Management

SPS’s strategy for managing suicide risks in prison “Act2 Care“ was enacted in 1998 and reviewed in 2005. The policy states that communication is vital to prevent suicides. Act2Care says:”It is essential that information be passed on concerning the person at risk so that the attention of others is drawn to ensuring that he/she continues to receive the best care possible.” The official policy further states that,”the clear recording of information on the relevant documentation is essential”.

The guidance also states that the families of vulnerable prisoners should be carefully listened to by the authorities.

However, SI has identified 16 deaths where Act2 Care was not followed properly. As far back as 2007 concerns were raised over the passing of information between agencies that handle prisoners.

During an inquiry into the death of Clark Isard, who hanged himself at HMP Perth in May 2007 the day after arriving, evidence was heard that information that Isard was a drug user suffering from withdrawal was not communicated. Isard had been prescribed medication to alleviate withdrawal symptoms while in police custody but this was not passed to HMP Perth.

A prison officer told the inquiry that one reason for placing a prisoner on observation was if he was suffering drug or alcohol withdrawal. The sheriff’s determination stated:”I cannot speculate but do consider that method by which such information is passed from one agency to another should be looked at by the appropriate persons.”

Despite this advice, a similar situation arose at HMP Perth less than one year later when another untried prisoner, Lee Russell, 30, hanged himself. The sheriff’s determination at the FAI began by stating there were similarities in the circumstances of Russell’s death and the suicide of Isard.

Russell was taken into custody on the 25th of March 2008 and took his own life during his first night there. The issue of information being passed between agencies that handle prisoners was again raised by the Crown. Russell had been prescribed medication whilst in police custody but once again that information was not received by HMP Perth and, as with Isard, withdrawal symptoms were not picked up by medical staff after he arrived at prison.

There were also a serious communication failure in the case of Stephen Cobb, 23, who hanged himself at HMP Saughton in April 2008. The FAI heard Cobb”cried like a baby” after being sentenced and had previously been on suicide watch in prison.

On the morning of 30th April 2008, Cobb was assessed under Act 2 Care as being at low risk of suicide but about an hour later he took his own life. Although a nurse enacted Act2 Care with a plan that included no razors and observations at a maximum of 30 minutes, Cobb was found dead in his cell after being left alone for more than the recommended time.

The evidence showed there was a breakdown in vital information being communicated to the hall where Cobb was held. The sheriff’s determination concluded there was no defect in the ACT 2 system per se, but there was a failure to operate the system as intended.

In the case of Thomas Strain, who hanged himself at Kilmarnock Prison in November 2008, a psychiatric report went missing and the FAI noted that staff made no attempt to locate it. Once again a sheriff made a number of recommendations to try to ensure that all relevant documentation accompanied prisoners from courts to prison.

The sheriff said:”I recommend that there should be a standardised practice whereby court staff contact the prison in advance to alert them when an incoming prisoner will be accompanied by a psychiatric report. I recommend that staff charged with carrying out risk assessments and case conferences should be instructed to take all reasonable steps to obtain copies of any potentially relevant medical or psychiatric report which is identified in respect of a prisoner.”

In June 2009, there was another suicide at HMP Perth when 22 year old Matthew Kirk hanged himself. Kirk was processed under ACT 2 but details of a suicide attempt in police custody and previous threats of suicide were not made available to the officers assessing him.

This was the subject of the sheriff’s determination that, “in terms of section 6(1)(c), a reasonable precaution whereby the death might have been avoided, would have been to have had in place a system of recording information about incidents known to the authorities, whereby a person in custody exhibits or has exhibited suicidal tendencies or ideation at the time of, during, or immediately before, being received into custody, on a record accessible to all officers subsequently responsible for his care in custody.”

At the FAI of Christian McIntosh, who hanged himself in Barlinnie in December 2009, it emerged his partner called the prison and told officers he had threatened to hang himself, but that information was not recorded on the deceased’s health record. Furthermore, a prison officer decided not to enact Act2 Care after receiving notification of the warning and it was 15 months later before the officer admitted to this.

A sheriff said the proper procedure had not been followed and that SPS should carry out a review. He recommended that where credible information is received by prisons that a prisoner has threatened to commit suicide, the information should be recorded in medical records and communicated to all those involved in the supervision and care of the prisoner.

There were more communication problems at Barlinnie Prison when Stuart Rose and Daniel Bell both committed suicide shortly after Christian McIntosh. Rose – a first time offender – collapsed in the dock after being sentenced in court on the 14th April 2010.

The FAI heard Rose was immediately seen by a social worker and a nurse who identified him as a suicide risk. However, a Personal Escort Record (PER) was not in front of staff at Barlinnie when Rose arrived at the prison and it was decided he was not a suicide risk. Rose was pronounced dead a day later at 1520.

In the case of Bell, who hanged himself at Barlinnie in August 2010, his PER also went missing. He too was assessed by prison staff as being at no risk of suicide despite the fact he tried to self-harm whilst in police custody.

The FAI heard Bell struck his head on the charge bar in a police station and tried to self-harm with a staple. As a result he was placed in an observation cell and examined by a doctor who completed a form identifying him as at risk. The PER was not available to prison staff at Barlinnie when Bell was assessed on arrival.

Furthermore, the FAI heard that Bell had previously tried to hang himself and had been on suicide watch in prison on 19 previous occasions. The sheriff said:”The evidence clearly showed that the PER and additional information was not available to either those conducting the reception risk assessment or those conducting the health care risk assessment. Clearly that was a mistake in terms of the policy expressed in the guidance notes and in the system as envisaged by management.”

In the case of Dale Mulholland who hanged himself in March 2011 at Greenock Prison the sheriff rule his death might have been avoided if procedures had been followed.

Scottish Inquirer found failures to follow Act2 Care guidance in relation to the deaths of Clark Isard, Mark Dixon, Thomas Tant, Lee Russell, Stephen Cobb, Thomas Strain, Richard Crompton, Matthew Kirk, Steven Gibb, Paul Murdoch, Dale Mulholland, William Millen, Christian McIntosh, Stuart Rose, Daniel Bell and John Usher.

The 42 prison deaths “undetermined” yet by a FAI occurred at the following prisons –

PrisonUndetermined Deaths
Castle Huntly3
Low Moss1
Perth 7

An abridged version of this investigation was published by the Sunday Mail on 4th March 2014.

Photo credit: Thomas Nugent | CC |

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