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Thematic Report into mental health and prison deaths identifies key areas for improvement but why hasn’t real action already been taken to learn lessons from past failures?

A recent report published by the Prison & Probation Ombudsman (PPO) shines a light on the poor state of mental health services in our prisons and collates the key lessons learned from their investigations into the deaths of 557 prisoners who died in custody between 2012 and 2014, including 199 self-inflicted deaths.

Mental ill-health is one of the most prevalent and challenging issues in prisons and is closely associated with high rates of suicide and self-harm in custody. 70% of the prisoners who killed themselves had one or more identified mental health condition.

As lawyers who advise bereaved families of those who have died whilst detained, in the vast majority of cases we see the deceased has suffered from some form of mental health problem. These can range from serious and enduring conditions to milder short-term problems. The inquests we are involved in look at whether any potential failings by prison officers and/ or healthcare professionals have in some way contributed to a prisoner’s death. This is also the focus of the PPO’s role in investigating deaths in prisons.

In our work we see the same failings again and again; with those with mental health conditions not being diagnosed or treated appropriately. This is borne out by the PPO’s thematic report which identifies a number of improvements that need to be made, indicating there are lessons that seemingly still need to be learnt despite failings being repeatedly highlighted by their investigations. Drawing them together in a way that allows them to be easily shared across the prison service is welcome and is certainly a step in the right direction. For those working in the field however, it is doubtful that anything in the report will come as a surprise, indeed much of what is highlighted for improvement appears to be common sense.

It is hardly new, for instance, to raise the importance of identifying mental health problems in the first place and then providing appropriate treatment. Yet the PPO identified that this remains variable across prisons, with a great deal of room for improvement. Challenging behaviour associated with mental illness is often treated by staff as a behavioural rather than as a mental health problem. Inevitably this leads to a punitive rather than a therapeutic response which for many with underlying mental health issues will only serve to exacerbate their condition.

We see numerous cases where there is poor information sharing, failures to make referrals to mental health professionals, inappropriate mental health assessments and inadequate staff training. In line with this, the PPO states that their investigations found a lack of coordinated care, little evidence of joined up working between prison and healthcare staff and staff failing to remind or encourage prisoners to take their medication.

Suggested improvements include mental health awareness training, access to a range of psychological and talking therapies and the implementation of systems for ensuring compliance with medication. The review also covers lessons to be learnt as regards health screening on reception into prison, prison transfers, continuity of care and making referrals.

The suggestions are helpful but the reality is that the ombudsman has very little power to drive these improvements through. We have seen the same mistakes repeated time and again at the same establishments, despite criticisms made by the PPO. In many inquests we have attended it appears that Prison Governors look at the recommendations in the PPO report when the Inquest takes place, and take some tokenistic action. However, sadly, it seems that this is not because they have taken the recommendations to heart and are determined to make real and far-reaching changes, but rather are trying to avoid Coroner’s making Prevention of Future Death Reports. Coroners have a duty to make such a report where conditions causing a risk to life continue to exist, as lessons haven’t yet been learnt. For example, we have seen hasty reminders to staff in relation to how policies operate circulated during the course of the inquest to show that some action has been taken when the evidence given by prison officers suggests otherwise.

Last year the Harris Review and the Chief Inspector of Prisons annual report both shared concerns that lessons are not being learnt. This included lessons from recommendations made by the PPO following deaths in custody and concerns raised by Coroners in Prevention of Future Death Reports.

There are however significant underlying problems that need to be tackled such as inadequate staffing, overcrowding, drug taking, and prison violence as well as poor quality healthcare provision. The government is very much aware of the need for change, and we await the outcome of David Cameron’s announcement on the ‘overhaul’ of the system earlier this year.

Learning lessons from deaths in custody should not be a tick box approach where staff are simply reminded of their responsibilities; meaningful action is needed to respond to mistakes made and to make changes to improve prison safety. Only then will we see a decline in the number of deaths of mentally ill individuals in our prisons.