List of acronyms ACCT – Assessment, Care in Custody and Teamwork ADR – Annual Data Requirement APP – Approved Professional Practice CQC – Care Quality Commission CR/HT – Crisis resolution/home treatment DH – Department of Health ECHR – European Convention on Human Rights
FAI – Fatal Accident Inquiry HIW – Healthcare Inspectorate Wales HMIC – Her Majesty’s Inspectorate of Constabulary HMICS – Her Majesty’s Inspectorate of Constabulary in Scotland HMIP – Her Majesty’s Inspector of Prisons HJIPS – Health and Justice Indicators of Performance HSCIC – Health and Social Care Information Centre HSIB – Health Safety Investigation Branch IAP – Independent Advisory Panel on Deaths in Custody IPCC – Independent Police Complaints Commission IPSIS - Independent Patient Safety Investigation Service MWC – Mental Welfare Commission for Scotland NCISH – National Confidential Inquiry into Suicide and Homicide by People with Mental Illness NHS – National Health Service NICE – National Institute for Health and Care Excellence NOMS – National Offender Management Service NPS – New Psychoactive Substances OPCAT – Optional Protocol to the Convention Against Torture PASC – Public Administration Select Committee PER – Person Escort Record
Total Natural Non-natural 2010 198 126 72 2011 192 122 70 2012 192 123 69 2013 215 131 84 2014 243 145 98 2015 257 146 104 Source: Ministry of Justice (2016), Safety in custody quarterly update to September 2015. Available [accessed: 19 February 2016]. Notes: Data are not available on the numbers of people with mental health conditions. Total for 2015 includes seven deaths, for which the cause is as yet undetermined. The rate of self-inflicted deaths was the same in 2014 and 2015, but the highest since 2007. Table 3.3 Numbers of deaths of people with mental health conditions in or following police custody Deaths of people with mental health conditions in or following police custody Total Natural Non-natural 7 3 4 8 1 7 5 2 3 6 4 2 7* 3 2 Source: IPCC, , 2016. ‘Additional data requested’. [Email communication]. Michaela Bartlett, . 22 January 2016: 11:44. Notes: IPCC publish data by financial year, therefore this data has been extracted for this report so that it can be compared against other data. * Cause of death is awaited for two cases. Research on deaths following release from detention During the course of our inquiry several respondents raised concerns about the number of people dying on release from prison or police custody. While outside the original terms of reference, we have since contracted researchers from Sheffield Hallam University to review the available evidence. The IPCC provided reports for the research. We were hoping to publish the outcome of this 1
implementing recommendations, improving staff training and ensuring more joined-up working. Where this is not currently the situation this should explicitly be part of the inspection regimes. All settings Organisations which do not deliver to the standards outlined in the Equality and Human Rights Commission’s Human Rights Framework risk being in breach of human rights obligations. Risk assessments need to be carried out, be effective, be reviewed regularly and shared with all relevant agencies and staff. Training in mental health awareness should be mandatory and ongoing for all frontline staff so they are better able to identify and appropriately support people with mental health conditions. There needs to be a clear process which sets out how the implementation of recommendations from investigations into a death (including the inquest) will be followed up. This is the joint responsibility of those who run individual institutions and the regulatory and inspectorate bodies which make those recommendations. We recommend increased statutory obligations on institutions to publically Department of Health Response: DH and NHS England take compliance with human rights obligations very seriously. The Commission’s Framework is a welcome additional resource to support organisations deliver safe and compassionate care. The revised Mental Health Act 1983 Code of Practice sets out detailed guidance on the importance of comprehensive risk assessments of those detained under the Act to ensure that their clinical needs are met whilst maintaining their safety and the wider public safety. NHS England currently commissions healthcare in prisons. Commissioned health services carry out risk assessments at reception and these are reviewed when health interventions are delivered. Providers of health services in prison settings are expected to support their staff in accessing
the extent to which action has been taken to address the recommendations of PPO investigations into recent deaths and includes information about this in their inspection reports. NOMS recognises that prison staff should be provided with an insight into common mental health issues and the need to refer prisoners to qualified specialists in line with their local provision. Over 17,000 prison staff received mental health awareness training between and this has since been incorporated into the initial training of all new prison officers. The Safer Custody suite of training for staff includes a module offering an Introduction to Mental Health, which is available for Governors and Directors to use if they wish to do so. Additionally, there is an enhanced mental health training package aimed at Assessment, Care in Custody and Teamwork (ACCT) assessors and case managers that they are required to complete before taking up their role. ACCT is a system designed to reduce the risk of suicide and