Title: Development and validation of a risk assessment tool for self-harm in prisoners
Funder: Department of Health and Social Care

Abstract: Rates of self-harm in prisoners are high and been increasing over the last few years. In 2015-16, there were 34,586 reported incidents of self-harm in 10,012 prisoners, a 27% increase on the previous year. One approach of the Prison Service to deal with these high rates has been to reduce the recurrence of self-harm, which is estimated at around 25% within 6 months. The current assessment of risk of recurrent self-harm on closure of a risk assessment management plan (also known as ‘Assessment, Care in Custody and Teamwork’ or ‘ACCT’) lacks a structured approach. Any reduction in self-harm will have large benefits for the Prison Service and NHS in reducing individual prisoner’s physical and psychiatric morbidity, attendant healthcare costs, possible disruption to release planning, and also improve the prison environment more widely. This project has three parts. 1. Development of a risk assessment tool We will develop the tool using routinely collected information for reasons of feasibility and ease of translation. It will aim to identify risk of repeat self-harm within 3 months following the closure of an ACCT. Following consensus guidelines for prognostic research, we will create a statistical model based on a pre-specified list of predictors based on previous evidence and new risk factors that will be tested in multivariable models. These factors will include socio-demographic, criminal history, and clinical ones, including those collected in the ACCT process, some of which are dynamic. In order to develop a robust model, we estimate requiring 150 new self-harm episodes in the 3 months post-ACCT. Assuming a self-harm rate of 20% in the 3 months post-ACCT closure, we anticipate needing information on 750 prisoners who have completed ACCTs for the development of the tool. We intend to extract these data from an existing database of more than 12,000 ACCTs held by one of the co-applicants (that will need some new information being supplemented from prison healthcare records and case files). 2. Qualitative study We will then assess the acceptability of the new tool to relevant stakeholders (prisoners, clinicians and prison staff) based in three settings (one local/short-sentence, one long-stay, and one female prison) and examine barriers to implementation. Using action learning processes, we will work with staff and prisoner groups over twelve months (via monthly sessions) to develop an implementation/operational pathway to embed the new tool within existing ACCT, post-ACCT procedures and any other relevant processes. 3. Prospective study As a next step, we will conduct a validation study, and prospectively test the tool’s predictive ability in a cohort of prisoners at the end of their ACCTs. We will sample adult male and female prisoners on ACCTs, from remand and sentenced prisons in different regions. The sample size will be partly guided by the results from the development of the tool, but we anticipate testing the tool on at least 500 prisoners. The cohort of prisoners will be followed up for 3 months to identify new episodes of self-harm (or suicide) in custody. Measures of discrimination (sensitivity, specificity, positive and negative predictive value, C-index) and calibration will be reported, and in order to consider how such an instrument could be used in practice – to identify high risk individuals or screen out low risk persons.

Lay abstract: Rates of self-harm in prisoners are high and been increasing for some years. Nearly a decade ago, the Ministry of Justice (MoJ) implemented Assessment, Care in Custody and Teamwork (ACCT), a risk management plan, to collect all important information for prisoners considered at risk of self-harm and suicide, to assist in reducing self-harm and suicide in prisons. In 2015-16, there were 34,586 reported incidents of self-harm in prisons, 7,271 more than the previous year (a 27% increase). A particular problem has been the assessment of risk of recurrent self-harm on closure of ACCT, for which no structured approach exists. Reducing self-harm and deaths by suicide in custody has been in the forefront of policy and strategy implementation from the MoJ. Self-harm in prisoners has considerable detrimental impacts on an individual’s health, social wellbeing, and may disrupt reintegration on release. It also effects other prisoners and staff as self-harm can be traumatic to witness. Additionally, it carries major resource and cost implications for healthcare in prison and external hospitals. Reduction of such risk is therefore important for the MoJ, the NHS, and public health more generally. There are three parts to the project as specified in the brief: i. Development of a risk assessment tool In the first year of this project, we will develop the tool using routinely collected data from prison healthcare records and ACCT documents. By using existing data, we will reduce unnecessary costs and complexities in data collection, and have sufficient sample size to make the development of the tool more robust. Using routinely collected data would also mean that no additional data collection effort will be required if the tool is implemented. One of the co-applicants has already extracted pseudo-anonymised data on over 12,000 ACCTs for a different project, and we intend to use these data in development of the tool. We aim to develop a tool that will identify the risk of repeat self-harm within 3 months post-closure of any ACCT. We will use the Prison Service’s definition of self-harm. Using the latest guidelines for prognostic research, we will create a statistical model to predict repeat self-harm. ii. Qualitative study The qualitative part of the project will assess acceptability of this new tool to relevant stakeholders including prisoners, clinicians and prison staff, and examine barriers to implementation. Using action learning processes, we will work with staff and prisoners, over twelve months to develop an implementation and operational pathway to embed the new tool within existing ACCT and post-ACCT procedures and other relevant processes. iii. Prospective study The third part will involve testing the instrument’s ability to predict risk of further self-harm (and suicide) in a cohort of prisoners at the end of their ACCTs. A sample of prisoners in London, Buckinghamshire, Lancashire and Yorkshire prisons will be followed up for 3 months to identify new episodes of self-harm (and also suicide) in custody. The new tool will be administered and scored by three researchers (two based in London and Oxford and one in Manchester) working independently from prison ACCT teams so that the tool's performance will not be affected by changes to the management of prisoners based on the tool’s score.

Research activity codes: 4.2 EVALUATION OF MARKERS AND TECHNOLOGIES
Health categories: INJURIES AND ACCIDENTS;MENTAL HEALTH