The criminal justice system is failing to prevent suicides among people released from custody

Deaths after leaving custody are often ‘hidden’ from proper scrutiny. Peter Macdiarmid/PA Wire

Getting released from prison or police custody can be a huge shock to those who have been incarcerated. Our new research gives an indication of just how vulnerable these people can be. We found that over a seven-year period, 400 people died of a suspected suicide within 48 hours of leaving police detention.

The number of people dying in prisons and in police custody has been increasing for several years. There is, rightly, a statutory obligation for every death that occurs within a state institution to be investigated by an independent body. So each death in a prison is investigated by the Prisons and Probation Ombudsman (PPO), while the equivalent in police stations are investigated by the Independent Police Complaints Commission (IPCC).

But for people who die shortly after release from police or prison custody, their deaths are not subject to statutory investigation and are too often invisible.

A dangerous transition

Our research, published by the Equality and Human Rights Commission, looked into non-natural deaths of people who have been released from police detention or prison custody. We found that the data on these deaths is contingent upon the relevant institutions (prisons, police or probation) finding out about the death in the first place – and this can be difficult.

We examined two sets of data: IPCC data on suspected suicides that occurred within 48 hours of release from police detention and data from the National Offender Management Service on deaths of people under probation supervision, which includes those released from prison. We also conducted interviews with 15 custody sergeants – police officers who are responsible for the welfare of a detainee while in a police station – prison officers and others such as representatives of police and crime commissioners (PCCs) and Public Health England.

The IPCC data suggest that 400 people died between 2009 and 2016 of a suspected suicide within 48 hours of release, although this number declined between the years 2014-15 and 2015-16, as the graph below shows. People who had been detained on suspicion of sex offences accounted for 32% of the 400 total suspected suicides.

We also examined a selection of 41 investigations and summaries of investigations into apparent post-release suicides that were provided to us by the IPCC. Half of these people had pre-existing mental health conditions. These referrals also pointed to inadequate risk assessment, record keeping and onward referral to relevant community-based care providers such as mental health or drug treatment providers.

We then looked at deaths that had occurred within 28 days of release from prison. Despite some issues with the accuracy and completeness of the data, we identified 66 people between 2010 and 2015 who had died from non-natural causes within 28 days of leaving prison. The numbers are small and so it is difficult to draw wider conclusions, but we found that 44 of those 66 died from a drug-related death. Of the 66, 35 had served a sentence for an acquisitive offence such as theft, shoplifting or robbery, offences which are commonly associated with drug use.

We also analysed investigations conducted between 2010 and 2015 by the PPO into deaths that occurred in approved premises, also known as bail hostels, within 28 days of release from custody. These investigations seek to understand what, if anything, could have been done to prevent the death. This highlighted problems with supporting drug-using offenders, a lack of confidence among staff and a failure to create a smooth transition from prison into the community.

Staff under strain

These analyses only tell part of the story. Our discussions with custody officers painted a complex picture. They argued that they were getting better at identifying people in custody with mental health conditions but that their ability to deal with them effectively was restricted by factors beyond their control such as a lack of appropriate treatment for people after leaving their care and an inadequate number of beds in mental health hospitals. They told us that the risk assessment tool they use for identifying such people was not fit for purpose because it did not go into enough detail and that they would benefit from additional mental health training. They were also strongly in favour of the responsibility for healthcare commissioning in police stations being handed to the NHS, rather than PCCs, a proposal which was dropped in December 2015.

The story from prison staff was similar, but they also talked about the use of new psychoactive substances and the negative effects these substances are having on mental health and safety in the prison.

Problems also exist when it comes to the provision of community-based care after people are released. These include cuts to community mental health services and drug services, as well as recent changes to the probation service, which have seen 70% of the service outsourced to the private sector. Such reforms have made communication between prisons and probation providers more difficult. These budget cuts and public sector reforms are having a serious impact on the ability of criminal justice agencies to deal with these issues and prevent any future deaths.

There needs to be an improvement in the way in which data on non-natural deaths is collected. Deaths post-detention should also be subject to similar levels of investigation as those that occur in police custody and prison. It would be naive to suggest that all deaths of people leaving state detention can be investigated, but there is scope for more oversight from both the IPCC and PPO, at least while they are adjusting to life back in the community. At the same time, the government must maintain investment in mental health and drug services to help prevent those most vulnerable when they are released from detention from taking their own life.

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