A DETENTION UNDER THE MENTAL HEALTH ACT 1983

  It may be helpful to consider this aspect of the inquiry under three headings, each relating to a different set of circumstances.

  (a)  Death by suicide and untoward incidents including homicide (Section A);

  (b)  Accidental death following the use of control and restraint (Section B); and

  (c)  Death by natural causes where neglect or an action by an agent of the institution may have contributed.

  Although there may be general and crosscutting issues to consider (such as the availability of means to commit suicide and the general availability of treatments for severe mental illness), every death merits an analysis of the individual circumstances. In many cases it is the combination of factors rather than a single cause that needs to be understood.

  A "human rights approach" to the management of settings can, and has been, helpful in preventing and investigating deaths in custody or deaths amongst those who are detained in a variety of settings. Section C contains examples from high secure hospital settings. Sections D and E contain information about the work of the Mental Health Act Commission (MHAC) and the causes or detention under the Mental Health Act respectively. Section F explains what is being done to reform the inquiry process.

  While the focus of the inquiry is on the settings in which people may be detained, it is also important to remember that it is possible for patients detained under the Mental Health Act to have home leave. This can be a time of high risk for them (see Sections A and D). This means that a focus on the whole system of care, including care planning and follow up, is as important as the care setting. Furthermore, this will become more important if the proposed reforms to the current law contained in the Mental Health Bill are implemented.

SECTION A: SUICIDE BY PEOPLE WITH A MENTAL ILLNESS

  Suicide accounts for 2% of all male and 1% of all female deaths and is associated with nearly half a million years of life lost for those under 75. It is now the leading cause of death for young men under the age of 25. Having a severe mental illness is a risk factor; for example, around a quarter of people who commit suicide have a severe mental illness and their lifetime risk is 10-15%.

  Three-year (rolling) averages are the usual way to record suicide and the latest figures for the three-year period 1997-2000 show a small rise (4.1%). Data for 1998-99-2000 (three-year average) show a rate of 9.4. deaths per 100,000 population—a rise of 4.1% over baseline (1995-97). However, although suicide rates fluctuate year on year, they show an overall downward trend since the early 80s. The suicide rate for the year 2001, the most recent available, was the lowest recorded (8.9 per 100,000). This is encouraging and if the rate remains low next year, the three-year average rate will fall.

  The likelihood of a person committing suicide depends on several factors. These include physically disabling or painful illnesses and mental illness; alcohol and drug misuse; and level of social support. Stressful life events such as the loss of a job, a death or divorce can also play a part. For many people, it is the combination of factors which is important, rather than any single factor. Because a significant number of suicides occur during a period of inpatient care, of shortly after discharge, managing risk effectively and ensuring good continuity of mental health care is essential.

In-patient suicides

  Following the Chief Medical Officer's report "An Organisation with a Memory", the Department of Health issued a directive that required all local mental health services to reduce to zero the number of suicides on acute psychiatric wards by ensuring that immediate action was taken to remove all non-collapsible structures such as bed, shower and curtain rails in all psychiatric in-patient settings. All Trusts have since complied. The chart below illustrates the fall in in-patient suicide in 2001.

Policy Background

National Service Framework for Mental Health (NSF) September 1999

  The Government's White Paper Saving Lives: Our Healthier Nation sets out a challenging target to reduce the rate of death by suicide and undetermined injury by one fifth by the year 2010.

  Standard Seven of the Department of Health's National Service Framework for Mental Health (NSF) (1999) sets out the action needed to achieve this. In addition, it sets out the action to be taken to support prisons in preventing suicides among prisoners by ensuring that staff are competent to assess the risk of suicide among individuals at greatest risk; and develop local systems for suicide audit to learn lessons and take any necessary action.

  Services were asked to:

—  review the physical environment in in-patient settings and make changes necessary to reduce access to means of suicide;

—  help prevent suicides amongst high risk groups, ie all patients with a current or recent history of severe mental illness and/or deliberate self harm, and, in particular, those who at some time during their admission were detained under the Mental Health Act because of high risk of suicide. They must be followed up (by a face to face contact with a mental health professional) within seven days of discharge from in-patient hospital care; and

—  develop local systems for suicide audit to learn lessons and take any necessary action.

National Suicide Prevention Strategy for England

  On 16 September 2002, the Department of Health published the National Suicide Prevention Strategy for England, the first of its kind in this country. It was developed under the direction of the National Director for Mental Health, Professor Louis Appleby, to ensure that we are doing all we can to prevent suicide in pursuit of the Saving Lives: Our Healthier Nation target. The strategy is a co-ordinated set of activities that will take place over several years and which will evolve as new priorities and new evidence on prevention emerge. It provides comprehensive, evidence-based guidance on the action needed to reduce risk; reduce the availability and lethality of means; and promote mental health.

  Implementation of the strategy is one of the core programmes of work of the National Institute for Mental Health in England (NIMHE). It will involve close working with a range of health and social care agencies, other Government Departments and voluntary sector organisations. NIMHE is also developing a toolkit to support the implementation of Standard Seven of the National Service Framework for adult Mental Health (suicide prevention). This is planned for publication in autumn 2003 and will include an audit tool and examples of good practice.

The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness

  The Department of Health funds the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness to ensure that everyone involved in mental health services learns and implements lessons from the factors associated with serious incidents. The inquiry is crucial to gaining a better understanding of the circumstances surrounding homicides and suicides committed by people with mental illness. The inquiry's fifth report "Safety First", which was published March 2001, says that of 1,579 homicides notified to the inquiry:

—  Around a third had a diagnosis of mental disorder, the most common being alcohol dependence, drug dependence and personality disorder (9%).

—  Only 15% (of the whole sample) had symptoms at the time of the offence.

—  Only 5% had a diagnosis of schizophrenia.

—  Most were male (ratio of nine men to one woman) and most were young (median age 27).

  The report recommended "Twelve points to a safer service" covering the most important policy and practice issues. These are intended as a checklist for local services where service development is supported through the NIMHE programme.

SECTION B: MANAGEMENT OF VIOLENCE AND USE OF RESTRAINT IN MENTAL HEALTH SETTINGS

Work in Progress

  Owing to concerns about safety in mental health settings expressed by users, carers and staff, a Cross-Government Group on the Management of Violence was set up and had its first meeting in October 2002. A number of progressive services already have policies and protocols in place but there is a need to share and disseminate positive practice. The Cross-Government Group will therefore develop guidance to help local agencies collaborate; promote and develop strategies on the management of violence, and support the development of policy between agencies on information sharing, referrals, custody procedures and training.

  NIMHE will appoint a project manager for two years from 2003-04 to work in partnership with the National Patient Safety Agency. The post holder will develop a proposal for accreditation of training and trainers; design and commission appropriate training; update the Mental Health Code of Practice, and convert current guidance into standards and audit. Mr Gary O'Hare has been appointed on an interim basis from 1 September 2003.

  The National Institute for Clinical Excellence (NICE) has been commissioned to develop guidance on the short-term management of disturbed (violent) service users in adult inpatient psychiatric settings. This should be available in August 2004.

  The Department of Health has funded the British Institute of Learning Disabilities (BILD) to establish a system of accreditation for trainers and programmes in the learning disability speciality.

  The Department of Health (DH) and the Department of Education and Skills have issued guidance for Restrictive Physical Interventions for people with learning disabilities and Autistic spectrum disorder.

  The National Assembly for Wales has drafted "Overarching principles and expectations to inform restrictive physical intervention policy and practice when managing challenging behaviour for health, social services and education settings", which will be issued in early 2004.

Work to be Developed

  The Department of Health has developed a Zero Tolerance campaign, which does not always fit with the philosophies of Mental Health Services and needs of service users. There is a requirement to interpret and adapt for mental health settings.

  The Home Office is working on principles for liaison between police and local mental health services into which DH officials will provide a health perspective.

  The National Patient Safety Agency has expressed an interest in taking forward an investigation of the use of restraint.

Background

  In February 2002 the United Kingdom Central Council for Nursing, Midwifery, and Health Visiting (UKCC) issued a report into the therapeutic management of violence in mental health care. It made a number of recommendations which included the need for appropriate training; the need to consider the issues of race, culture and ethnicity; and standards relating to skills in physical interventions and physical care. It also recommended that:

—  Policies and principles should be developed on controversial issues, such as the use of CS Spray, the institution of criminal proceedings against patients, mechanical restraints, pain compliance and other legal, ethical and human rights issues.

—  Research should be commissioned into the safety, effectiveness and professional acceptability of de-escalation techniques, seclusion and physical interventions.

  Following the death of David Bennett, the then Minister of State at the Department of Health (Jacqui Smith) gave a commitment to Dr Joanna Bennett to write to her ministerial colleagues for their support in delivering a more consistent cross-Government approach on restraint. This was also stated in the adjournment debate of 9 November 2001. The most recent meeting of the Cross-Government Group was held in July 2003.

  Concerns about safety expressed by users, carers and service staff. There is evidence of concern from services in respect of Health and Safety imperatives, injuries to patients and staff, European Human Rights legislation, ethical issues, the increasing use of substance misuse, presence of weapons and the need for searching. A number of progressive services have policies and protocols but there is a need to share and disseminate positive practice.

  MHAC—The reform of the Mental Health Act and the revision of the Mental Health Act Code of Practice, taking account of modern approaches to mental health care, more enlightened approaches to prevention and management of disturbed behaviour and the need for close collaboration and co-operation between the Police and other agencies to reduce risk.

SECTION C: HIGH SECURITY HOSPITALS

Human rights awareness

  The high security hospitals provide the most secure settings available within the NHS and accommodate the most potentially dangerous mentally disordered patients. This means that robust security arrangements need to be put in place. However, there is a need to strike the right balance between considerations of security and therapy. The general principle is that good security should provide a safe environment for patients and staff in which therapeutic activities can flourish.

  Human rights issues are very much to the forefront of thinking about policy and procedures in the high secure hospitals. For example, the Fallon Inquiry into Ashworth Hospital identified shortcomings and inconsistencies in the security arrangements at Ashworth Hospital. As a result the high security hospital Safety and Security Directions were drawn up to bring robust and consistent security arrangements across the three high security hospitals sites.

  These Directions were scrutinised carefully for compliance with human rights legislation and, in view of the Department of Health, struck the right balance between human rights considerations and legitimate security concerns. Nevertheless, some patients and staff feel that the pendulum has swung too far towards security. Consequently, there have been a number of human rights related challenges/threatened challenges to the Directions, none of which have so far been taken successfully through the courts.

  Amongst the security and human rights considerations it is important to bear in mind in relation to the high secure hospitals:

—  The Mental Health Act 1983 Code of Practice has been complied with human rights issues in mind. For example, the first guiding principle on page three of the Code states that people to whom the 1983 Act applies should receive recognition of their basic human rights under the European Convention on Human Rights.

—  In paragraph one on page one of the Code it is stated that the Act does not impose a legal duty to comply with the Code but it is a statutory document and failure to follow it could be referred to in evidence in legal proceedings. The Code has a high profile and a high status; and routine monitoring is undertaken by the Mental Health Act Commission.

  Examples of issues challenged include:

—  The arrangements for listening into/recording some patient telephone calls.

—  The restrictions on visitors bringing food and tobacco into the hospitals for patients.

—  The arrangements for searching patients and visitors.

—  The control on the volume of possessions that patients may keep in their rooms.

  Other human rights related challenges include:

—  Against the seclusion policy at Ashworth Hospital (on the grounds that it did not fully comply with the Code of Practice).

—  Patients being treated for a disorder that they were not classified for under the Act (eg a patient legally classified as mentally ill being treated for a personality disorder). Both these challenges were successful but may be appealed.

Deaths in untoward circumstances

  Action taken by high security hospitals to prevent deaths in untoward circumstances:

—  All deaths in untoward circumstances are investigated with a view to learning lessons for the future.

—  Observation levels are increased for patients who are thought to be at risk of self-harm/suicide.

—  There are robust commissioning and performance management arrangements in place, one of the objectives of which is to improve the treatments and activities available to patients and thus improve their quality of life and hopefully reduce the danger of self-harm/suicide.

—  Central funding has been provided to aid the removal of ligature points. Efforts have also been made to make seclusion rooms safer.

—  Life saving equipment is available (eg defibrillators are available to all wards and staff are trained to use them).

  Other action that may serve to reduce self-harming and suicidal intent:

—  There have been delays in moving patients out of the high security hospitals. This may, for some patients, have increased any suicidal tendencies. The Department of Health has initiated an accelerated discharge programme (NHS Plan Commitment) to reduce the problem of delays in moving patients out of the high security hospitals. This is linked to the wider development of secure psychiatric services to facilitate the movement of patients to whatever is the most appropriate level of security at any given moment in time.

—  The number of women patients in high security is being significantly reduced through the accelerated discharge programme such that only one site, rather than all three, will need to provide such a service. Alternative, more appropriate, services are being developed for women who do not require high security.

—  The high security hospitals have become less isolated by virtue of their integration into NHS Trusts. This has improved links with the wider NHS easing staff exchange, etc. As a result the high security hospitals are developing more of an NHS ethos.

—  There have been some reductions in ward sizes (patient numbers). There are plans for further reductions but they depend on funding being made available.

—  General health care advice to patients is improving, although there is still room for improvement.

SECTION D: MENTAL HEALTH ACT COMMISSION (MHAC)

  The MHAC is a special health authority with responsibility for monitoring and reviewing MHA implementation as it relates to patients who are detained or liable to be detained under the Act in England and Wales. The MHAC publishes a report every second year on its rolling programme of visits to all hospitals and nursing homes, and its findings based on reviews of patient records, examination of policies and systems, and meetings with detained patients. The report for 1999-2001 was laid before Parliament in 2002. Although it is not possible to address all the recommendations, a sample of important issues arising from the report are highlighted below.

Information

  Chapter 2 concerns patients' rights. The report comments that, where patients do not understand their legal position, it is often as a result of poor practice in providing communication at an appropriate level and checking that it has been understood. Although there is no evidence that poor or inadequate information has led to or contributed to deaths, it is likely to be important in adding to a sense of isolation amongst those with severe mental illness and/or depression who are at risk.

  The MHAC recommended action to reduce the stigma of mental illness (being taken forward by the NIMHE) and to ensure patient information is adequate in an appropriate range of languages and formats. NIMHE's programmes on the mental health of black and minority ethnic communities and strategy for people with mental illness who are deaf are both relevant here.

Deaths of Detained Patients

  The MHAC maintains a record of every patient who has died whilst subject to detention under the MHA and inquires as to the circumstances. Its most recent report considers the deaths of 1,471 patients over a three year period, of whom hospital staff reported that 1,218 died of natural causes (an estimated rate of 822/100,000 sections per annum for 1997-2000). The most significant finding is that 47% of such patients died within one month of admission and 18% between one month and 10 weeks.

  Two hundred and fifty three (17%) of the 1,471 cases resulted in an inquest. Of these, 168 verdicts were recorded as suicide or "open" verdicts, 31 as accident or misadventure, four due to drug abuse and five as natural causes. Only 2% of the unnatural deaths were among people over the age of 75. The majority (78%) were under the age of 45 years and most (72%) were men. Almost half of those who died an unnatural death were diagnosed as having schizophrenia and 20% were diagnosed as having depression. Hanging was reported to be the cause of death in 40% of suicides and 16% of deaths by accident or misadventure—pointing to the importance of removing ligature points.

  Analysis of the cases reported as suicide (or open verdicts thus classified) indicates that younger people detained because of a mental disorder are more at risk than older people. 25% (41) of suicides occurred whilst the patient was being observed every 15 minutes—which emphasises the importance of reviewing observation procedures. This is a point also made in the 1999 Report of the National Confidential Inquiry.

  Only 32% of unnatural deaths occurred within a psychiatric unit, and the remainder occurred whilst the patient was on leave. This finding is consistent with the findings of previous reports and reinforces the importance of risk assessment and management, security and policy on granting leave under Section 17 of the Act, particularly if a patient fails to return at the expected time. Thirty one (12.5%) of deaths were categorised as accidental (18 men and 13 women, most under the age of 45) and almost a third of these were in psychiatric wards.

  Among the deaths reported to a coroner, the MHAC information showed 22 instances in which restraint had been used in the week before death and two of these concerned patients from African or Caribbean ethnic cultural groups. Although the small numbers make it difficult to assess statistical significance, the MHAC recommended attention to this, especially as there is a relatively high number of people from black and minority ethnic groups who are detained under the MHA.

  The MHAC makes a series of recommendations concerning their findings on risk assessment, data capture (including about ethnicity), the use of restraint, analysis of deaths by hanging, removal of means to assist suicide, and audit and inquiry after a death by suicide.

SECTION E: MENTAL HEALTH ACT (1983) DETENTION

  This Annex contains an extremely brief overview of the provisions of the Mental Health Act 1983.

  The MHA governs all aspects of compulsory admission to hospital, as well as the treatment, welfare, and aftercare of patients. It provides for mentally disordered persons who need to be detained in the interests of their own health, their own safety or the safety of others. The Act sets out when and how a person can be "sectioned" and ensures that the rights of detained patients are protected.

  The Act sets out the rights of people who are detained to have information about the reasons for the detention; an explanation of the relevant section; information about the right to appeal to the Mental Health Review Tribunal; information about care and treatment; information about social security benefits; information about how to complain; and about plans for discharge.

  Section 1 of the Act defines mental disorder in terms of mental illness, mental impairment, severe mental impairment, or psychopathic disorder. Mental impairment means a state of arrested or incomplete development of mind, including significant impairment of intelligence and social functioning which is associated with abnormally aggressive or seriously irresponsible conduct. Psychopathic disorder means a persistent disorder or disability of mind resulting in abnormally aggressive or seriously irresponsible conduct.

  An individual with a mental disorder may be compulsorily admitted to hospital where this is necessary:

—  in the interests of his or her own health, or

—  in the interest of his/her own safety, or

—  for the protection of other people.

  Only one of these grounds needs to be satisfied in addition to those relating to the patient's mental disorder.

  Section 2 concerns admission for assessment or admission for assessment followed by treatment for up to 28 days. Section 3 concerns compulsory detention for treatment up to six months. Section 4 concerns admission in an emergency and section 5 is for emergencies amongst those already in hospital. The Act also covers circumstances for people subject to criminal proceedings (sections 37, 37/41, 47 and 48). Section 2 and 3 treatment orders may not be applied unless treatment could not be delivered without them. Treatment can be delivered without consent in those circumstances for up to three months.

  The Responsible Medical Officer (RMO) can agree to specified periods of leave, possibly with conditions attached, although some sections are restricted and the Home Office must be informed.

Reform of the 1983 Act

  A draft Mental Health Bill and Consultation document was published for consultation between 25 June and 16 September 2002.

  Mental health legislation sets out the circumstances in which people can be treated for mental disorder without their consent and the safeguards to which they are entitled.

  The Bill will replace the current Mental Health Act 1983 and is the first major overhaul of the system since the 1950s. The objectives are:

—  to make significant improvements to patients' safeguards;

—  to provide a modern framework of legislation in line with modern patterns of care and treatment and human rights law; and

—  to protect public safety by enabling patients to get the right treatment at the right time.

  The Bill forms a vital part of the Government's wider strategy to improve and modernise mental health services for all. This includes increased investment and current reform of services.

  The vast majority of people with mental health problems are not a risk to anyone and will never need compulsory treatment. However, there is a small number of patients who need compulsory treatment, mainly for their own safety, and on very rare occasions for the safety of others. The Bill aims to ensure that these seriously ill people receive the treatment they need.

  It will break the automatic link between compulsory treatment and detention, allowing patients to be treated in the setting most appropriate to them. Treatment in the community will provide a positive alternative for the many patients who do not want or need to be detained in hospital and an opportunity to minimise the disruption to their lives.

  It will introduce new rights and safeguards for patients, including:

—  A requirement for every patient to have an individual written care plan.

—  All compulsion beyond 28 days to be authorised independently by the new mental health tribunal.

—  Access to new specialist mental health advocates to support patients and their nominated person.

  The combination of the new definition of mental disorder and the tight set of conditions for compulsion can ensure that all patients, whatever their diagnosis, will be considered on the basis of their individual needs.

  The Bill aims to strike the right balance between safeguarding the rights of individual patients and protecting patients from harming themselves or others.

  The Department of Health received nearly 2,000 responses to the consultation exercise. It is now completing and refining the Bill in the light of those responses to ensure it achieves the intended effect. A new Mental Health Bill will be introduced as soon as Parliamentary time allows.

SECTION F: REFORM OF THE INQUIRIES PROCESS

  The then Minister of State for Health (Jacqui Smith) announced in 2002 that the Government intended to reform and strengthen the process of inquiries following homicide by a person with a mental illness. The National Patient Safety Agency (NPSA) is road testing "Root Cause Analysis", the approach outlined in the Chief Medical Officer's report "Building a Safer NHS for Patients" published in 2001.

Background

  "Safety First", the fifth report of the National Confidential Inquiry into suicide and homicide by people with mental illness, was published March 2001. The report says that, of 1,579 homicides notified to the inquiry:

—  Around a third had a diagnosis of mental disorder, the most common diagnoses being alcohol dependence, drug dependence and personality disorder (9%).

—  Only 15% (of the whole sample) had symptoms at the time of the offence.

—  Only 5% had a diagnosis of schizophrenia.

—  Most were male (ratio of nine men to one woman) and most were young (median age 27).

  The key issues in the guidance issued by the Department of Health, HSG (94) 27, are that:

—  In the event of a homicide committed by a person in contact with specialist mental health services an inquiry into the treatment and care provided should be commissioned and this inquiry should be independent of the providers of care.

—  Responsibility for commissioning such inquiries was recently transferred from the former health authorities to the strategic health authorities. This makes the most sense in view of Primary Care Trusts' increasing involvement in service provision.

—  The National Patient Safety Agency, part of the Modernisation Agency, is currently road-testing the "root cause analysis" approach for homicides committed by a person in contact with specialist mental health services.

—  A number of external stakeholders, such as the Royal College of Psychiatrists are actively involved in the process of advising on reform. For example, Jayne Zito has a particular interest following her work to strengthen systems of care and investigations of incidents after the death of her fiancé at the hand of Christopher Clunis.

B DEATHS IN PRISON CUSTODY

How does the prison healthcare system seek to prevent deaths in prisons, in particular through mental healthcare and drug detoxification programmes?

  The Prison Service's published objective is to provide prisoners with access to the same range and quality of health services as the general public receives from the National Health Service (NHS). In pursuing achievement of this objective, it seeks to go considerably further than just meeting the obligations in Articles 2, 3, and 8 of the European Convention on Human Rights (ECHR).

  Amongst key epidemiological factors which influence views on suicide and self-harm in prison and their prevalence, prevention, assessment and management are the following:

—  Prisoners are known to be most vulnerable to suicide during their first day, first week and first month in custody, and during similar periods of time following their transfer to a different prison.

—  It is well known that 90% of prisoners have at least one significant mental health problem (Psychiatric Morbidity amongst prisoners in England and Wales Office for National Statistics 1998). One fifth have four out of five of the major categories of mental health disorders considered in the ONS survey (psychosis, neurotic disorder, personality disorder, drug dependence and alcohol misuse).

—  The National Confidential Inquiry report in to the Suicides in Prison (1999-2000) found that 72% of those who died had at least one psychiatric diagnosis recognised on their reception into prison. This was at a time when the Prison Service was poor at identifying mental ill health during the reception screening process so it is possible that an even higher number of those who died had a mental disorder. The commonest mental disorder identified was drug dependence. Sixty two per cent of those who died had a history of drug misuse and 30% of alcohol misuse; only half of whom had been referred to the prison healthcare service.

—  Ninety two per cent of self-inflicted deaths in prison are the result of hanging; very importantly the commonest ligature being bedclothes. Twenty five per cent of those who died had open 2052SHs, indicating the recognition of risk but 75% did not. This is no worse than for suicides in the community, where only 2% of people who died had been recognised as being at high risk.

  These facts about the epidemiology of suicide and self-harm in prison have informed management policies in a number of ways.

RECEPTION ARRANGEMENTS

  Research indicated that the Prison Service's reception screening processes were failing to identify up to three-quarters of the prisoners who had a severe mental illness. To rectify this, new triage-based reception screening arrangements were developed and piloted during 2001-02 at 10 local prisons. They focus on identifying and managing a prisoner's immediate and significant health needs on first reception into prison custody, so that more effective use can be made of existing staff resources and skill mix. This work has been closely linked to development of the Prison Service's suicide prevention strategy and four of the reception screening pilots also form part of the Prison Service's Safer Locals Programme. Evaluation of experience at the pilot sites showed a substantial improvement in the identification of prisoners with a severe mental illness. The new reception health screening system is being phased in at all local prisons over a 12-month period that began last April.

  Significantly, evaluation of the new reception screening tool at the pilot prisons revealed that only 3% of receptions, when asked, stated that they were suicidal. Only two individuals in this group had no mental disorders. All the others were identified through the reception screening tool as having either a significant mental illness or an addiction to alcohol and/or drugs, or both.

THE CLINICAL MANAGEMENT OF SUBSTANCE MISUSERS INCLUDING DETOXIFICATION

  The Prison Service expects good quality clinical substance misuse services, including detoxification, to be available in all local prisons and remand centres. Its Standard for Health Services to Prisoners requires all establishments to have in place a written and observed statement of their substance misuse service which must be in line with the latest Department of Health guidance on drug misuse and dependence (1999).

  The general health examination/assessment a prisoner receives on first reception into custody aims to identify past and present drug usage and engagement with community drugs teams. A clinical decision is then reached about the next steps in the management of each individual prisoner. This can be either detoxification of substitute prescribing, as a prelude to a broader based drug treatment programme.

  Prison Service Order (3550), (December 2000) introduced a new Standard for Clinical Services for Substance Misusers, which concerns the effective clinical management of the substance misuse treatment service provided by staff working in prisons. It is in line with current Department of Health guidelines for such a service, forms part of the overall Prison Service Drug Strategy, and underpins delivery of the Prison Service Standards of Health Services for Prisoners and Drugs. It was designed to ensure, once fully implemented, that good quality clinical substance misuse services are available in all local prisons and remand centres to a level that is at least comparable with those in the community.

  The Standard requires all establishments to have in place a written and observed policy statement on their substance misuse service. All prisoners must have immediate access to detoxification programmes for opiates, alcohol and benzodiazepines in line with Department of Health guidelines (1999). They must be provided with information about substance misuse treatment services, health promotion and harm minimisation.

  The Standard also requires establishments to have evidence-based guidelines for maintenance prescription which are also in line with the current Department of Health guidance. Is specifically indicates that maintenance prescribing is likely to be suitable for prisoners on remand or serving short sentences who have been maintained on methadone in the community and for whom there is evidence that engagement in such a programme has had a beneficial effect. Such programmes are also indicated for pregnant women and people with serious physical illnesses.

  Guidelines should include information about maintenance on naltrexone and its use in relapse prevention management.

  The Standard goes on to say that, as new evidence becomes available on the chemical management of detoxification or abstinence, establishments should develop further treatment guidelines which are in line with those available in the National Health Service.

  The National Treatment Agency (NTA) has undertaken a considerable amount of work in conjunction with the Department of Health on the prevention of drug-related deaths. Prison Health and the Prison Service's Drug Strategy Unit are both members of the NTA's drug-related deaths working party, thereby ensuring that its work is relevant to prisoners and the prison setting. A significant amount of harm minimisation material has been developed for treatment providers, service commissioners, general health providers, drug users, and marginalised groups, which, when published, will also be available and applicable to prisoners and prison staff.

MENTAL HEALTH SERVICES

  Despite the best efforts of the Prison Service, the majority of deaths occur in people who have not been recognised as being vulnerable to suicide at that time. It is known that death is most likely to occur during the first month in custody, for the person to have a mental health problem, most likely a drug problem. This confirms the importance of continuing with the current approach, which is to assess and manage those prisoners whom staff identify as vulnerable through self-report or emotional distress. It also highlights the importance of treating all prisoners decently and humanely at all stages of their time in prison custody and of continuing to improve the assessment and management of prisoners with mental disorders and/or dependence on drugs and alcohol.

  The work that is currently underway to improve mental health services in prisons should be seen in the context of the government's overall strategy for improving prison health care generally, and is being taken forward within that framework. Concern about the quality of health services available to prisoners increased during the early and mid-1990s. The Home Secretary and the Secretary of State for Health jointly set up a Working Group of officials from the Prison Service and the NHS Executive to consider the future organisation of, and ways of improving, prisoners' health care. The strategy that is now being implemented stems from the findings and recommendations of that Working Group, as set out in its Report "The Future Organisation of Prison Health Care" (1999). The basic principles were succinctly summarised as follows:

"Healthcare in prisons should promote the health of prisoners; identify prisoners with health problems; assess their needs and deliver treatment or refer to other specialist services as appropriate. It should also continue any care started in the community contributing to a seamless service and facilitating through care on release".

  One of the source documents used by the Working Group was an earlier Report of the Independent Standing Health Advisory Committee for the Prison Service, "The Provision of Mental Health Care in Prisons" (1997). That report stressed the importance of "equivalence", that is, that the mental health services available to prisoners should be of the same type and range, and of the same quality, as those available to NHS patients in the community. The Joint Working Group accepted this principle, both in terms of mental health services and of prison health care generally, and it formed the starting point of all their recommendations, and of the prison health care strategy developed subsequently.

  The prison population is now around 74,000, and over 140,000 are received into custody each year, most only staying for a short time before being released back into the wider community. It has been estimated that around 90% of prisoners can be diagnosed as suffering from at least one of the five main categories of mental disorder (psychosis; neurosis; personality disorder; alcohol misuse; drug dependency). Around 20% of those on remand and 12-15% of those serving sentences suffer from four out of the five. On any one day in prisons in England and Wales there will be around 5,000 prisoners with a severe and enduring mental disorder.

  The Department of Health's NHS Plan (July 2000) included the following specific commitments on the provision of mental health services for prisoners:

"Within the new partnerships between the NHS and local prisons, some 300 additional staff will be employed.

By 2004, 5,000 prisoners at any time should be receiving more comprehensive mental health services in prison. All people with severe mental illness will be in receipt of treatment, and no prisoner with serious mental illness will leave prison without a care plan and a care co-ordinator."

  The government's strategy for developing and modernising mental health services in prisons, Changing the Outlook, a Strategy for Developing and Modernising Mental Health Services in Prisons was published in December 2001. It set out a vision of where prison mental health care was expected to be in three to five years time and identified the steps that would have to be taken if it were to be realised.

  Referring specifically to suicide prevention, paragraph 3.24 of Changing the Outlook stated:

"Nine per cent of all suicides in prison occurred during the first 24 hours in custody, 27% during the first week, and 43% during the first month. The Director General of the Prison Service has made it clear that he considers suicide prevention to be one of the key objectives of the Prison Service. The mental health NSF gives it the same emphasis by including it as one of the seven standards and by identifying prisoners as one of the key vulnerable groups within the standard which the NHS should be specifically targeting. Thus both the Prison Service and the NHS have been given a clear responsibility to work together in this field. The Prison Service has recently launched a new strategy for suicide prevention, and piloting has begun in five prisons. On the NHS side, the first wave sites for mental health in-reach deliberately include those five establishments, in acknowledgement of the vital links between mental ill health and suicide. However, providing effective care and treatment for suicidal prisoners will be a key task for all prisons, not just those involved in these initiatives."

  The basic principle underpinning the prison mental health strategy is that services should be provided, as far as possible, in the same way as they are in the wider community. Prisoners who, were they not in prison, would be treated in their own homes under the care of Community Mental Health Teams (CMHTs), should be treated on the wings, their prison "home". Those needing more specialist care should be able to receive it in the prison Health Care Centre, and there should be quick and effective mechanisms to transfer those requiring specialist in-patient treatment to hospital. Any prisoners already receiving treatment for mental health problems in the community through, for example, the Care Programme Approach, should continue to have access to that level of service while they are in prison and, if appropriate, on release.

  The prison mental health in-reach project, which began in 2001, is the mechanism through which the specific commitments in the NHS Plan are being implemented. Dedicated funding has been made available from the NHS budget to support the introduction into prisons of multi-disciplinary teams which are designed to provide mental health services for prisoners along the lines of the community mental health teams which already provide mental health services in the community at large. The project began at 18 establishments in England and the four in Wales in 2001-02, and was extended to another 26 sites during 2002-03. During this financial year in-reach teams are being developed in another 46 establishments. So far more than 150 additional NHS staff have become involved in providing mental health services in prisons. That number will double by the end of 2003-04, as the target in the NHS Plan is met. Between March 2004 and March 2006 it is expected that NHS mental health in-reach investment will double. This should mean that within the next three years there will be in-reach type services available to every prison in England and Wales. The extra investment will also support many of the existing teams in expanding the services they can offer.

  Changing the Outlook signalled the intention to establish a prison mental health collaborative to support and empower staff to modernise clinical services for prisoners with mental health problems. This collaborative is now well underway, in partnership with the National Institute of Mental Health and the NHS Modernisation Agency. It involves training and empowering groups of clinical staff to make improvements in clinical practice. Amongst its objectives are the establishment of an infrastructure to identify and share good practice and the identification of the training requirements needed for modernising clinical services. It is also concerned with empowering staff to make decisions about their own services and to realise small areas of change and it aims to be a means of bringing about better peer group support and improved satisfaction for service users.

  Prison Health has funded an evaluation of in-reach that is being commissioned through the NHS Forensic Research and Development Programme. It has also established a transition group to oversee the transfer of responsibility for prison mental health policy development and implementation to the National Institute of Mental Health in England (NIMHE). It will assist the Prison Service's Safer Custody Group to establish links with NIMHE.

  There is, however, more to the mental health strategy than the in-reach project. Prisons already spend anything up to half their total health care expenditure on mental health care. Every prison is expected to look critically with its NHS partner at its existing provision to establish whether it meets the needs identified in the Health Needs Assessment and is in line with the principles and standards set out in both the Mental Health NSF and Changing the Outlook. In many cases a very medicalised model was in place which took little account of recent developments in mental health care and did not allow for modern multi-disciplinary approaches. The strategy will mean a period of major change for virtually every establishment. It must be recognised also, that change will not happen overnight but will be an evolutionary process over several years. Some establishments will be able to progress faster than others.

TRANSFER TO HOSPITAL

  Prisoners who need in-patient treatment for their mental disorders should be transferred to hospital as soon as possible. Generally speaking, the arrangements for assessments and transfer in such circumstances work smoothly and very many prisoners get transferred to hospital quickly. But problems of apparently excessive delay can still occur in some individual cases. This can give rise to distress in the prisoners themselves, their families and friends and also the prison staff responsible for looking after them while they wait for a hospital place. Prison Health and NHS Regional Commissioners of Forensic Mental Health Services have looked at ways to reduce the time prisoners may have to wait for a hospital place. In parallel tighter regular monitoring has been introduced to identify prisoners who have been waiting unacceptably long periods for transfer to hospital. All establishments must provide regular returns to the headquarters Prison Health team showing how many prisoners are awaiting either assessment or transfer, and of the latter, how many have been waiting for more than three months following acceptance. A protocol has been issued which sets out the actions required of both the Prison Service and the NHS when a prisoner reaches that three-month deadline.

INFORMATION SHARING

  The importance of information sharing in assisting to prevent self-inflicted deaths is well recognised. Prison Service Instruction 25/2002. "The Protection and Use of Confidential Health Information in Prisons and Inter-Agency Information Sharing" and its associated Information and Practice note were issued in May 2002. They require prisons, generally with the prisoner's consent, to request any information required from a prisoner's GP or other relevant service with which he/she has recently been in contact. They also provide guidance on information sharing with other agencies, particularly the NHS, and provide a framework for developing effective inter-agency information sharing, including information sharing protocols. The issue of detailed guidance on best practice for information sharing within current legal requirements and professional codes of conduct should increase staff confidence in sharing information in appropriate circumstances, in particular when a patient is at risk.

  Following publication of Changing the Outlook all prisons, in collaboration with their local NHS partners, will have completed a detailed review of their mental health needs and developed action plans to fill any gaps in service provision they identified. The challenge to all concerned if the desired degree of improvement in prison mental health services is to be achieved is considerable. Nevertheless we expect over the next three years or so to see all, or at least most, of the following outcomes:

—  Fewer mentally disordered prisoners accommodated in prison health care centres, with resources re-deployed to provide day care and wing-based support.

—  A reduction in the average length of time mentally disordered prisoners spend in those prison health care beds that remain.

—  A more appropriate skill mix among those who are providing mental health services in the prison setting.

—  Quicker and more effective arrangements for transferring the most seriously ill prisoners to appropriate NHS facilities and receiving them back.

—  Closer collaboration with NHS staff in the management of prisoners who are seriously mentally ill, including those who may be vulnerable to suicide or self-harm while they are in prison.

Are any further measures being considered to address the problem of deaths in custody?

  While there has been substantial progress in the provision of non-clinical drug services across the prison estate, clinical services have been slower to develop. Detoxification, of a pre-set duration, remains the solitary prescribing response to drug dependence in the majority of local prisons. However, while detoxification may remain the preferred method of clinical management for some drug-dependent prisoners, it is recognised that other treatment options are required to manage problems, including the growing issue of suicide and self-harm during the period of withdrawal. The Prison Service's review of prevention of suicide and self-harm in prisons recommended that special attention should be paid to the safe management of prisoners in the early stages of custody in a prison. This should include a focus on excellence of care for all prisoners in reception, first night, induction and detoxification units. A broader range of clinical responses to drug dependence, such as extended detoxification and maintenance programmes, can help to reduce incidents of suicide and self-harm among those at risk, particularly prisoners with co-existent drug and mental health problems.

  To address this and other problems Prison Health has been developing a clinical management model to cover up to the first 28 days of a prisoner's period in custody. It has recently begun to seek observations from a range of key agencies and professional bodies on the form and content of this proposed model.

FURTHER RESEARCH INTO SUICIDE AND SELF-HARM

  Prison Health is continuing to fund "The Confidential Inquiry into Prison Suicide", a three-year study being undertaken by University of Manchester. An Interim report is due to be delivered this Autumn. In addition "cases" will be analysed against controls, ie prisoners who did not die. Such a study helps to get closer to the precipitating factors for death. For example, rather than saying drugs are implicated in suicide in prison we may have a clearer view that it may be heroin or cocaine only, both in combination. Prison Health is also funding a study to ascertain the influence of supporting staff at Holloway prison who are dealing with women prisoners who self-harm.

Are you satisfied that guidance and practice in the prison healthcare service is sufficient to comply with obligations under Articles 8, 3, and 2 of the European Convention on Human Rights?

What has been done to foster awareness of human rights in the prison healthcare service? Could a human rights approach to prison healthcare contribute to the prevention of deaths in custody?

  The continuing programme to achieve significant reform and improvement of the organisation and delivery of health services to prisoners, begun in April 2000 on the basis of a new partnership between the Prison Service and the NHS, is designed to go much further than complying with the requirements of these Articles of the ECHR. In the written evidence he sent to Ms Roisin Pillay on 18 August, the Director General of the Prison Service responded to these questions on behalf of the Service as a whole and his response applies in respect of health care staff.