Twofold rise in female prisoner suicides linked to 'inadequate' mental health support in prisons, report finds

An alarming rise in suicides among female prisoners has been linked to “inadequate” mental health provision in UK prisons, prompting urgent calls for more to be done to prevent women in custody from taking their own lives.

A bulletin by the Prison and Probation Ombudsman, which draws on a review of 19 cases of female suicides over the past three years, highlights a "lack of urgency" among prison staff in responding to indications of mental illness, and warns of a lack of communication between mental health staff and prison officers in preventing self-inflicted deaths.

There were 12 female suicides in prisons last year, compared with seven in 2015 and between one and three each year before that since 2006 — marking a "tragic rise" that the Ombudsman said “shows little sign of abating”.

For the first time since 2007, the number of female suicides per 1,000 prisoners in 2015 was higher than that among men, with overall deaths of female prisoners more than doubling in 2016 compared to the previous calendar year.

Female deaths in prison are most commonly categorised as self-inflicted, in contrast to those among men, where natural cause deaths are most common. Ministry of Justice data show that there are 3,869 female prisoners compared to 80,988 in the male estate, representing five per cent of the total prison population — yet women account for 23 per cent of all recorded incidents of self-harm.

The sudden increase led to calls for the bulletin, which by reviewing investigations into self-inflicted deaths of female prisoners who died over the period seeks to highlight common issues and lessons in order to contribute to improved safety in prisons.

It warns of a lack of urgency or timeliness in the actions taken by mental healthcare staff, citing cases where the mental health care was “not found to be equivalent to that the woman could have expected to receive in the community.”

While the investigations reviewed found that decision making around mental health was broadly “sound” and care from individual healthcare staff was “good”, the bulletin points at a “clear theme of poor joint working between mental health and custodial staff”, stating that some prison officers were unaware they could refer a prisoner for a mental health assessment.

The bulletin states that the cases reviewed demonstrated the need for an effective emergency response, which “may have meant the difference between life and death”, and warns of problems around not ensuring the input from mental health professionals who could have contributed to risk monitoring.

One case cited in the bulletin was a woman, named only as Ms B, who was found collapsed on her bed with a plastic bag on her head five days into her prison sentence — a death the report suggests could have been prevented with better information sharing and more swift and sufficient support from mental health staff.

Despite having a long history of mental illness, including psychotic phases and unstable personality disorder — as well as regularly self-harming — the bulletin states that the woman “did not receive a referral to a consultant psychiatrist, nor was she allocated a mental health care coordinator”.

According to the clinical reviewer of the case, “no one showed any sign of urgency” in recognising that the woman needed more care than was available, and the report concluded that “Ms B did not get sufficient support from trained mental health staff and there was a general lack of input from mental health into the prison’s inpatient unit”.

Aside from the need to more effectively address mental health issues, other important areas of learning identified in the bulletin include better assessment and management of risk, improving suicide and self-harm prevention procedures and combating bullying and ensuring timely emergency responses.

Baroness Jean Corston, who was appointed in 2006 to conduct a major review into the experiences of vulnerable women in the criminal justice system, told The Independent the problems were primarily due to recent cuts to prison staffing and the length of time it takes for women with severe mental health needs to be sectioned.

“There have been huge cuts in prison staffing. These women need constant supervision. They need people who know them, who understand how they behave and can keep an eye on them," Baroness Corston said.

“Under Chris Grayling, there have been 30 per cent cuts in prison officer staff, and you cannot look after these women when you don’t have enough staff.

“Furthermore, women are now waiting a long time to be sectioned. I have personally been in a prison and seen a highly disturbed woman who could not be sent anywhere. I was told no bed could be found for her."

Prisons and Probation Ombudsman Nigel Newcomen, who drew up the bulletin, said: “I find it disheartening that many of the lessons we identify to prevent women in custody from taking their own lives repeat those in previous publications from my office.

“This suggests it is not knowledge that is the issue, but a lack of concerted and sustained action. While we often identify examples of excellent and compassionate care by individual staff, and also recognise that prisons have been under enormous strain in recent years, there can be no excuse for not implementing essential safety arrangements that could ensure vulnerable women are better protected.

“It is to be hoped that delivering safer outcomes for women (and men) in prison will be at the heart of the Government’s new prison reform agenda, and that this bulletin can assist with this and help to reverse the unacceptable and tragic rise in self-inflicted deaths.”

In response to the findings, a Government spokesperson meanwhile said: “The safety of those in our custody is a priority and all prisons have procedures in place to support those at risk of committing self-harm or suicide.

“We have increased the support available to vulnerable offenders - especially during the first 24 hours in custody - and have invested more in mental health training for prison officers.

“More funding has been allocated to prison safety, and we have launched a suicide and self-harm reduction project to address the increase in self-inflicted deaths and self-harm in our prisons.

“We are also working closely with NHS England and Public Health England to improve mental health services for offenders at all points of the criminal justice system and to address these issues in our establishments.”