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TRYING TO REDUCE PRISON SUICIDES About 15 years ago I was working as a Medical Officer in a Scottish prison. I was learning the job. One of my duties was to attend when someone had hanged himself and to certify him dead. Of all the things I had to learn about prisons, the most distressing was the reaction of people to death. On one occasion I was greeted with glee: “One off the numbers, Sir!”. On another, I found a nurse standing with his foot on the dead man's chest and the ligature around his neck not completely removed. I regularly discussed problems with the other medical officers and mentioned my reaction to this. One of them answered: “That's nothing – the screws used to put their cigarettes out in their ears!” I thought about this over a few weeks. I had trained first to become a dentist and took medicine to progress to Oral Surgery, but had not yet obtained a senior registrar job. I took this prison medical officer job for further training. I hoped I was not going to become insensitive, like a guard in a concentration camp. I determined to try to do something about this problem of suicide by hanging. I started by looking back at the records of previous deaths. Each year there had been about seven hangings amongst some 1000 inmates. I thought I could help to reduce this. I didn't know much about psychiatry, but I could resuscitate somebody. The notes revealed certain common factors. Of particular note was the presence of sedating drugs detected at post-mortem. It was often difficult to determine who had prescribed these and why. There was an abundance of visiting doctors and psychiatrists, who seemed to drift in and out. I thought we needed a better means of recording and investigating the reasons for death (an embryonic idea for clinical audit). Of the deaths I attended, hanging had crushed the larynx and it appeared they were only just dead when I arrived. I needed a defibrillator, and a means of reducing the crushed larynx. (I was asked recently by an inexperienced prison medical officer “couldn't you do a cricothyrotomy?” I felt this illustrated that he had never seen a hanged man; the larynx is disimpacted, completely squashed and the cricothyroid membrane unidentifiable.) Everything in prisons has to be discussed with the prison governors who were the managers. I did this and was grateful to be allowed to purchase a defibrillator and use it, even though they thought I was a ‘prat' and a ‘maverick doctor' if I went ahead with the purchase; they certainly weren't going to authorise payment from prison funds. I have found language in prisons very ‘robust' and in my immaturity then quite liked it. I bought a Laerdal Heartstart 2000 semi-automatic defibrillator and intubation equipment, and undertook training in their use. It was one of the first in a UK prison in constant readiness. I informed the governor about this, and said that I hoped that the defibrillator would never need to be discharged, but if it was I would inform him in writing. It happened very soon. The first attempt to revive a hanged man was not successful. We were not quick enough. Soon I had enough staff enthusiastic about preventing death and after about the fifth success the governor authorised for me to be reimbursed for my outlay. With the money I bought a computer and attempted to embark on audit, using GPASS software. My letter to the BMJ ( Prison Environment encourages conflict - September 1993) was one of my early efforts to share my experience. It seemed to me that, rather than attempt to rely on resuscitation, we should make efforts to prevent suicides in the first place. To do this we needed to improve our assessment of risk, and our routines when risk was assessed as high. I began to receive an exponential increase in help from others, particularly one doctor whom I found to be an expert at preventing suicide, using his talent with his weekly religious fellowship group with inmates. He teaches that religion is important to many humans, especially those in adversity as were our patients. He also emphasised how important it is to understand other people's beliefs, especially when dealing with conflicts. The patients also received great help from social workers planning for their release. Despair becomes much reduced when there is a plan prepared for the patients' family and friends. I missed that input later when working in Wales , where the preparation for release is by ‘probation', whose energies seemed to be taken up mostly by sex offenders. Our team of doctors, nurses, social workers and prison officers in the Scottish prison developed a basic system of suicide risk assessment. This is now available in medical literature (e.g.: Suicide in custody: Case–control study Fruehwald et al, Br J Psychiatry 2004 185: 494-498.), but we added two more indicators to theirs: “crime patient alleged to have committed” and “whether a person felt unjustly treated by the court”. We did not place a great emphasis on violence, since the patients we were dealing with did not seem to be predominantly those accused of violent crime. Psychoactive drug usage was definitely a problem. Our exercise illustrated how important computer recording was going to become if we were to advance in this endeavour, but all prisons I have worked in are very reluctant to provide computerised recording. After about two years of success, it was very distressing when failure recurred. The team began to unravel. A new governor came from a prison with a high suicide/self harm rate, and she was not used to seeing incidents dealt with so vigorously. Prison staff became discouraged: “why should we spend so much time monitoring vulnerable people?” Not long ago the then Home Secretary was reported to have said that he opened a bottle of champagne when a particular prisoner hanged himself and died. This was the sort of statement I heard in the mid-nineties, when our embryonic system began to unravel. It became virtually impossible to reinvigorate the staff again. The doctor who had helped me left. Perhaps after some time the staff needed to re-learn the importance of resuscitation? Our study was, of course, no more than local and anecdotal, and no general inferences can be safely made; it was not a controlled scientifically based experiment. Records have not been maintained, so only the most tentative conclusions can be offered. We just seemed to stop a run of suicides for nearly two years. One point of interest is that after each successful resuscitation we made a point of asking the patient whether he was glad to be alive. They all said they were; it was as if the period of anoxia had lifted their depression. No one ever said they wished we had left them hanging! This small study, conducted without academic backing, illustrates the great difficulty in maintaining any complex system. Perhaps I have the skills to initiate, but not those to maintain? It was very difficult to re-establish control, although it was achieved partially. It was very distressing to have to deal with a series of assaults by staff upon inmates, and I chose a method that eventually led to my leaving and moving to Wales where I did not have this particular problem; that is a different story….. But suicides did happen in Wales too. I attacked the problem in a similar way (concentrating on assessment) but without having the same degree of religious and social work support. We seemed to be able to identify those at risk, but not able to do much to prevent incidents. Also, I was distressed to find that prescription drugs detected at post mortem had not been prescribed in writing. One day two nurses came to me and informed me that the consultant forensic psychiatrist had been authorising the use of psycho-active drugs without written prescription; exactly as I had detected had been occurring nearly ten years before in Scotland , when I was trying to deal with a high death rate. I reacted with ‘robust' prison language that did not go down well. The doctor in question departed, but left behind a difficult atmosphere. The suicide rate, which was my chief concern, came under control again. CONCLUSIONS Despite our knowledge of what has to be done, it is illustrative of continuing prevailing attitudes that these questions are often not even asked at inquests and inquiries. Perhaps people don't really want to know? It is my personal view that the system we had developed in Scotland is capable of reducing significantly the number of fatalities in custody. Situations vary, but deaths in prisons remain too numerous because some people do not wish to adopt proven methods to reduce suicide. I have attempted to elucidate why that may be so. |