Prison Suicide Prevention Paradigm Shift Study by Dr. Karen Slade

Shifting the paradigm of prison suicide prevention Dr Karen Slade C.Psychol (forensic) Nottingham Trent University Karen.slade02@ntu.ac.uk

Background Suicide in offenders remain a key priority with rates of 100 per 100,000 compared with 12 per 100,000 in the community (DoH, 2013; MoJ, 2015). Suicide rates have been rising again since 2012 after a period of reduction (up to 50%) after the introduction of national evidence-based structure and policies from 1999. Suicide remains stubbornly difficult to reduce and huge proportion of remand/early stage prisoners exhibit risk factors (Slade et al, 2014).

Study Prison A Local remand/early stage prison in South London, over 200 years old. (Re-rolled to a Cat C in early 2012) Had a consistently high suicide rate with a general average of 2.1 SIDs per year & 7 SIDs in 3 years between 2005-7. In March 2008 a new senior management team appointed incl. a senior lead for suicide prevention across the prison. Through 2008-9 a large number of changes were undertaken on an establishment-wide scale to tackle suicide risk and practice. No additional specialised suicide prevention individual or group interventions were included.

Outcome SELF-INFLICTED DEATHS AT STUDY PRISON 4 3 3 3 2 2 2 2 2 1 1 1 1 1 1 1 1 0 0 0 0

Outcome Poisson Regression confirmed a significant rate change before and after 2008 (p<0.0001) with likelihood of 2:100,000 occurring by chance. Cost Saving: Approx 11 million saved if compared with average expected rate of 6.3 SIDs over 3 years.

Study To explore the mechanisms by which organisational change reduced the suicide rate between 2008- 2011. To compare the findings with the WHO guidance on preventing suicide in jails and prisons (2007). Triangulate from a wide range of evidence sources

Method Questionnaire developed, in collaboration with prison staff, included 41 items listing: i) all changes at the prison which may directly influence suicide prevention ii) other major prison changes. Rated by 17 participants as to the importance to suicide prevention. Recorded Interviews with 7 professionals engaged in suicide prevention throughout 2008-2011 (healthcare, prison officer, senior officer, psychologist, ACCT assessor, regional and local suicide prevention lead and two senior Governors) Review of HMIP inspection reports (2008 & 2011) & audit reports (2008 & 2010).

Results All aspects of the WHO (2007) guidance were confirmed as relevant with 4 considered to be significantly more relevant plus 2 additional factors. 1. Prison Climate and Culture 2. Communication & Active Collaboration regarding high-risk prisoners 3. Mental Health treatment and integration 4. Debriefing staff and learning from incidents 5. Management and Leadership Approach 6. Specialist Knowledge

Prison Climate and Culture Staff attitude and relationships: compassion and listening Very low use of segregation Suicide prevention as 1 of 3 strategic priorities & integrated in wider decision-making

Communication & Active Collaboration regarding high-risk prisoners Complex cases Fortnightly and truly integrated decision-making and action planning (senior level & front-line) Healthcare wing partnership Single care planning system Ending black hole of information Controversial

Mental Health treatment and integration Multi-agency integration away from silo working Introduction of primary care MH team MH staff at primary care and substance use meetings

Debriefing staff and learning from incidents Swift and in-depth internal reviews with immediate changes to practice as recommendations identified Monthly senior-level reviews of all actions from DIC and Near-Miss from previous years and not complete unless permanent. Ongoing staff support and structured constructive advice and feedback

Management and leadership approach (incl. staff accountability) Positive and hopeful attitude Clear, transparent and obvious priority Physical presence of senior managers, encouraging person communication Offering hope and support to front-line staff Supporting innovation and individual risk management with clear expectations Twice-weekly feedback to staff on assessments and care plans Daily bite-sized policy directions: tip of the day Holding staff to account

Specialist knowledge for strategic management To guide and advise on major organisation change, training provision and support services with knowledge and experience of : working across disciplines and complexities of both prison and health policy risk management Prison suicide management and evidence-base Senior level required Equipped with skills to manage complex inter-disciplinary negotiations

Previously it had felt inevitable but {we} gave this prison hope that we could stop it (Governor H)

Conclusion National policies and procedures provide the backbone for local processes. Locally-informed innovative establishment-wide approaches are effective in reducing suicide when resources limited for specialist services. Suicide rate reduction possible through senior management supported cultural and practice change built upon good structures. However, must be collaborative and integrated across services & developed with a clear understanding of the local environment, the population and evidence-base.

Limitations & Strengths Retrospective perception prison didn t realise how good it would be until they had done it! In-vivo study amongst extensive changes: many not directly focused on suicide prevention and some took time to come to fruition. Triangulation approach to capture stronger and most consistent elements for reducing suicide. Lessons can be translated into practice; because they came from practice over the long-term. No prisoners able to be included due to re-roll of prison

Contact Paper to be published shortly: Slade, K. & Forrester, A. (2015) Shifting the paradigm of prison suicide prevention through enhanced multi- agency integration and cultural change Journal of Forensic Psychiatry and Psychology Dr Karen Slade: Nottingham Trent University karen.slade02@ntu.ac.uk Dr Andrew Forrester: South London and Maudesley NHS Trust. Andrew.forrester1@nhs.net.uk