National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, Centre for Suicide Prevention, University of Manchester, Manchester
Correspondence: Jenny Shaw, National Confidential Enquiry into Suicide and Homicide by People with Mental Illness, Centre for Suicide Prevention, Williamson Building, University of Manchester, Manchester M13 9PL, UK. E-mail: Jennifer.J.Shaw{at}man.ac.uk
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ABSTRACT |
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Aims To describe the clinical and social circumstances of self-inflicted deaths among prisoners.
Method A national clinical survey based on a 2-year sample of self-inflicted deaths in prisoners. Detailed clinical and social information was collected from prison governors and prison health care staff.
Results There were 172 self-inflicted deaths: 85 (49%; 95% CI 42-57) were of prisoners on remand; 55 (32%; 95% CI 25-39) occurred within 7 days of reception into prison. The commonest method was hanging or self-strangulation (92%; 95% CI 88-96). A total of 110 (72%; 95% CI 65-79) had a history of mental disorder. The commonest primary diagnosis was drug dependence (39, 27%; 95% CI 20-35). Eighty-nine (57%; 95% CI 49-64) had symptoms suggestive of mental disorder at reception into prison.
Conclusions Suicide prevention measures should be concentrated in the period immediately following reception into prison. Because hanging is the commonest method of suicide, removal of potential ligature points from cells should be a priority.
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INTRODUCTION |
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METHOD |
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Prison statistics
The ratio of men to women in the prison population is 18:1
(Home Office, 2002), 16% of
prisoners are aged 21 years or under (Home
Office, 2002) and 19% are remand prisoners
(Home Office, 2002).
National clinical survey
Information on all self-inflicted deaths in prisons in England and Wales
between 1 January 1999 and 31 December 2000 was forwarded by Her
Majestys Prison Service Safer Custody Group. These deaths were those
considered to be suicides or probable suicides by the Safer Custody Group,
regardless of a subsequent inquest verdict. It is conventional for studies of
suicide to include probable suicides in which another verdict was reached,
usually an open verdict. In this study we also included verdicts of
misadventure and accidental death if the death occurred by hanging.
Data collection was based on methods used by the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, to investigate suicides by people under mental health care (Appleby et al, 2001). For each self-inflicted death the prison medical officer and prison governor were asked to complete questionnaires in consultation with other members of staff who knew the prisoner. The questionnaires covered:
The prison medical officers questionnaire asked whether the prisoner had seen a psychiatrist and, if so, information on mental health was obtained from the psychiatrist, who was asked to complete a similar questionnaire.
Statistical analysis
Data were analysed using the Statistical Package for the Social Sciences
(SPSS), Version 10. Estimates are presented as proportions, with 95%
confidence intervals given for the main variables. If an item of information
was not known for a case, the case was removed from the analysis of that item;
the denominator in all estimates is, therefore, the number of valid cases for
each item.
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RESULTS |
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Completed questionnaires were returned by prison medical officers in 157 cases (91% response rate), by prison governors in 163 cases (95% response rate) and by psychiatrists in 29 cases (69% response rate).
Rates of suicide
The average total prison population for 1999 was 64 771 and for 2000 it was
64 602. The average rate of suicide per 100 000 population per year for 1999
and 2000 was 133; the age-standardised rate in the general population in
19992001 was 9.4 per 100 000. The rate for women was 184 per 100 000
population per year, and for men it was 129 per 100 000 population per year;
the age-standardised rates in the general population in 19992001 were
4.5 per 100 000 in women and 14.5 per 100 000 in men. In young age groups, the
male suicide rates exceeded 20 per 100 000 in the same 3-year period.
Location
The 172 suicides occurred in 65 prisons, with 12 prisons (10 for adult
males and 2 young offenders institutions) experiencing five or more deaths.
Five suicides occurred under the Prison Escort Custody Service. Fifty-eight
(34%) suicides were in shared cells but in 30 the cell mate was absent at the
time of death.
Timing
A total of 55 (32%; 95% CI 2539) suicides occurred within 7 days of
reception into prison, 19 (11%) of them within 24 h. Early suicides were more
common in drug-dependent prisoners: 22 (59%) died within 7 days of
reception.
Method
The commonest method of suicide was hanging or self-strangulation (159
cases, 92%; 95% CI 8896). Thirteen individuals (8%) used a method other
than hanging. There were six (3%) cases of self-poisoning, four (2%) of
cutting or stabbing, one of burning, one of suffocation and one other
(unspecified). The commonest ligature was bedclothes (89, 56%) and the main
ligature points were window bars (76, 48%), a bed (17, 11%) and cell fittings
such as lights, pipes, cupboards, sinks, toilets or doors (29, 18%).
Social and criminological characteristics
Table 1 shows the social and
criminological characteristics of all prison suicides. The ratio of men to
women overall was 12:1 but in those under 21 years of age it was 6:1.
Thirty-one (18%) were aged 21 years or under.
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Forty-one (26%; 95% CI 1933) were charged with or convicted of a violent offence. Eighty-five (49%; 95% CI 4257) were on remand. The suicide rate per 100 000 population per year for remand prisoners was 339 (see above for general population rates).
Clinical characteristics
Table 2 shows the main
clinical characteristics of the 157 suicides on whom questionnaires were
returned by prison medical officers. Information from psychiatrists is also
included where applicable.
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A total of 110 (72%; 95% CI 6579) prisoners had at least one known psychiatric diagnosis. The commonest primary diagnosis was drug dependence (39, 27%; 95% CI 2035). Ten (6%; 95% CI 311) had a diagnosis of schizophrenia and 26 (18%; 95% CI 1225) had a diagnosis of affective disorder. The most frequent secondary diagnosis was drug dependence. A history of drug misuse, alcohol misuse, previous self-harm and violence were common.
Reception screening
In 89 (57%; 95% CI 4964) cases, symptoms of mental disorder were
detected at reception to prison, most commonly intoxication or withdrawal from
drugs or alcohol (43, 27%), anxiety (27, 17%), thoughts of self-harm or
suicide (25, 16%), or depression (25, 16%). Forty-six prisoners (30%; 95% CI
2337) were known to have had contact with mental health services prior
to their prison term. Twenty-four (15%) had no contact with health care staff
after reception.
Information transfer
At reception, 110 (70%) prisoners reported having a general practitioner,
but he/she was contacted for information in only 18 cases (16%) and in only 10
(9%) was this within 1 week of reception. Of the 46 prisoners (29%) with a
history of contact with NHS mental health services, an attempt was made to
gather information from the service in only 17 cases (37%).
In-patient and post-discharge suicides
Twenty-seven (17%; 95% CI 1122) suicides occurred in prison health
care in-patient centres. We received detailed clinical information on 26 of
these. Twenty-one (81%) had been admitted because of mental health problems,
most often (10 cases) an act of deliberate self-harm or the expression of
suicidal ideas. Fifteen (60%) died within 7 days of admission to in-patient
care. Eleven (42%) were under medium or high levels of observation at the time
of death.
A further 45 (29%; 95% CI 2236) had previous admissions to prison health care in-patient centres. Nineteen (12%) had had multiple admissions during this prison term. In 30 (67%) the final admission had lasted less than 7 days. Sixteen (36%) died within 7 days of discharge from prison health care and in 12 (27%) no follow-up appointment with a health care professional was made. The remainder had a post-discharge follow-up appointment with health care staff, visiting psychiatrists or both, but in 10 (30%) of these the suicide occurred before the appointment took place.
F2052SH forms (for prisoners regarded at risk)
Eighty-five (51%) prisoners had an open F2052SH form at some time during
their sentence. Thirty-eight (24%; 95% CI 1831) prisoners had an open
F2052SH form at the time of death.
Perceived risk at final contact
In total, 141 (90%) of this sample could be considered at high risk of
suicide because of previous history of contact with NHS mental health services
(46), a lifetime history of mental disorder (110), current symptoms (89),
current treatment (53) or a history of drug misuse (95), alcohol misuse (46)
or self-harm (78). However, most suicides were thought to be at no or low risk
at their final contact with services.
Prevention
Prison health care teams regarded only 22 (15%; 95% CI 921) suicides
as preventable. However, more often they suggested factors that could have
made suicide less likely, including: closer supervision (69, 46%), better
staff training in risk assessment (39, 26%), placement in a cell with another
prisoner or a listener (39, 26%), increased staff numbers (34, 23%), better
prisoner support and clinical management (33, 22%) and better communication
between staff (31, 21%). Interestingly, staff made no mention of limiting
access to means/ligature points as a way of preventing suicide in individual
cases. Deaths in prisoners on an open F2052SH form or in health care
in-patient centres, in convicted prisoners and in those under 21 years of age
were more likely to be seen as preventable.
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DISCUSSION |
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Methodological issues
This study is primarily a clinical survey carried out on prisoners judged
to have died by suicide. This gives rise to four important limitations of the
findings.
First, without control subjects, aetiological conclusions cannot be drawn. Many of the risk factors for self-harm and suicide are common to prisoners in general. However, the findings show the characteristics of people in whom suicide must be prevented if prison suicide rates are to be reduced. Because many of these characteristics are risk factors for suicide in the general population, it seems likely that they were also part of the causal pathways that led to suicide. We are about to begin a casecontrol study that will provide data to allow the relative importance of individual and service-level risk factors to be determined.
Second, clinicians and other prison personnel completing questionnaires may have been biased by their awareness of outcome, and this may have affected, in particular, their reporting of estimates of risk at last contact. However, most items in the questionnaire were factual and should not have been affected by any bias in the respondents.
Third, the recommendations on suicide prevention (below) have not been subject to major clinical trials. Even so, we believe that they represent good practice on suicide prevention and are also likely to benefit non-suicidal prisoners.
Fourth, suicide rates were not standardised by age and are not strictly comparable with the general population figures presented here. However, the rates among prisoners are substantially higher than rates in the comparable age and gender group in the general population.
Implications for suicide prevention in prisons
In a high-risk population, identifying those at highest and most immediate
risk is difficult. These results suggest the need to recognise the fluctuating
and long-term nature of suicide risk in prisoners, to monitor risk continually
and to link supervision and other preventive measures to regular assessment. A
system of care planning of this kind should now be considered as an
alternative to current prison procedures based on the F2052SH form.
The findings in this paper also identify the days following reception into prison as the period when suicide prevention measures are most needed, and hanging as the main suicide method to prevent.
Some measures that should be taken are listed below.
A full list of recommendations is presented in the Safer Prisons report (Shaw et al, 2003).
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Clinical Implications and Limitations |
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LIMITATIONS
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REFERENCES |
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Received for publication April 10, 2003. Revision received October 15, 2003. Accepted for publication November 3, 2003.
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