Suicides of prisoners came just weeks after watchdog warned of safety risks
Published 10/10/2011 | 02:26
The suicide of two young Northern Ireland prisoners came just weeks after an official inspection of facilities raised serious concerns over the safety of inmates, it has emerged.
A health watchdog said immediate action should be taken to reduce the risk of suicide among prisoners at Hydebank Wood Young Offenders’ Centre (YOC) and Ash House Women’s Prison following inspections in March.
The damning report by the Regulation and Quality Improvement Authority (RQIA), which includes 113 recommendations for prison and health bosses, revealed a series of startling failings in the management of prisoners at risk of self-harm or suicide.
In particular, the team expressed concern no action had been taken to prevent prisoners from using beds to attempt suicide. The report said: “Despite a death and the recent suicide attempt having occurred in the YOC, which used the old metal-style beds as a ligature point, these beds have not been replaced.
“As a priority, a detailed risk assessment of cells in relation to ligature points should be undertaken as a matter of urgency by the Northern Ireland Prison Service with South Eastern Health & Social Care Trust and should include a detailed action and management plan.”
However, less than two months after the inspections were carried out, 23-year-old Frances McKeown and 19-year-old Samuel Carson — both prisoners at Hydebank — died by suicide within hours of one another. Ligatures were found in both cells.
It is unclear whether the recommendation made by RQIA relating to ligatures has ever been carried out.
Asked to state when this was done, a Northern Ireland Prison Service spokeswoman said: “Remedial action is already under way following the deaths in custody at both Hydebank Young Offenders Centre and Ash House.”
Jim Wells (left), deputy chair of the Stormont health committee and a member of the justice committee, said mental health provision for prisoners must be urgently addressed.
“This is something both committees will be looking at,” he said.
“The fact remains 90% of all prisoners suffer from mental ill-health or some kind of addiction yet they do not appear to be getting the help they need.”
A spokeswoman from the South Eastern Health & Social Care Trust, which is responsible for the delivery of healthcare in prisons, said a service improvement board has been put in place and many of the recommendations have been addressed.
She said: “Staff remain employees of the Northern Ireland Prison Service and this presents difficulties in terms of supervision and governance. However, health staff will become employees of this Trust by April 2012.
“Mental health staff are now working solely to deliver mental health services and no prisoner is waiting to be assessed for mental health services. Additional staff have been recruited .
“A consultant psychiatrist, occupational therapist and additional counselling and cognitive behavioural therapy sessions have been deployed into Hydebank Wood.”
The spokeswoman said the Trust has also asked the Health & Social Care Board for additional resources. A spokesman from the board said the request is currently being considered.
If you have been affected by suicide, or would like to speak to someone about the issue, call the Samaritans confidential phoneline on 08457 90 90 90.
Shocking report reveals catalogue of errors
Some of the most shocking incidents uncovered by the RQIA panel include:
- A young man was found unconscious in his cell after using laces as a ligature secured to bed - five months earlier another young prisoner died by suicide in similar circumstances.
- A nurse requested a medical unlock amid concerns over a prisoner but it was more than an hour before this happened because the prison officer was involved in another incident.
- The prisoner was treated for ingestion of lighter fluid she took from an unlocked storage room.
- Two days later the same prisoner injected herself with a potentially lethal dose of insulin which she said she stole from a treatment room. It emerged the treatment room was never locked and the lock on the drug fridge was faulty.
This was never reported and one member of staff said the lock was faulty from the day it was delivered.
It took 83 minutes between establishing the prisoner had taken an overdose and taking her to A&E because of the need to arrange escorting staff and make up an escape pack. The senior officer on duty declined to provide an account of events and there were no other incidents in the prison to explain the delay.
Only one set of observations was taken from the prisoner during the delay.
- A female prisoner was asked to interpret for a young man of the same nationality in a matter which related to description of intimate parts of the male body.
This was unacceptable according to her culture. She was referred for a mental health assessment and was still waiting for an appointment six months later. She told inspectors she was still being asked to interpret.
- There were no specialist Child and Adolescent Mental Health Services (CAMHS).
- A resuscitation grab bag did not contain emergency drugs, personal protective equipment (PPE) or a blood spills kit.
- A code for medical emergencies was not included on a small laminated card of tannoy call codes and emergency telephone numbers for use by inspectors.
- One man with homicidal and suicidal ideas went without healthcare involvement for at least four days.
- Procedures for confirming current medication and prescribing medication at committal was unsafe.
- Records for disposal of medicines not maintained.
- Young offenders and female prisoners did not have appropriate levels of exercise and opportunities for outdoor activity.
- Mental health services were under-resourced and the overall findings indicated provision of psychiatric support services was inadequate.