• Mental health trust launches review after 10 prisoners die in one year
  • Two patients committed suicide within nine days of each other in February
  • Suicides in prison have doubled since 2012

A mental health trust which runs prisons services is launching a review of the way it handles deaths in custody after concerns that such incidents are not being investigated in a “robust” way.

Ten patients died at four prisons where Oxleas Foundation Trust provides care between April 2016 and March 2017. Seven patients died in custody the year before.

Four of the deaths are thought to be self-inflicted, while according to the trust the remaining six appear to be deaths from natural causes.

The prisons were Thameside, Belmarsh, Emley and Swaleside.

The self-inflicted deaths include two patients who committed suicide within nine days of each other in February 2017, the trust’s April board papers said.

Oxleas decided to launch the review following concern that “there is insufficient assurance that the trust oversight and coordination of deaths in custody investigation process is robust”, according to the board papers.

The situation is complicated by the fact that the trust shares responsibility for the care of the prisoners with a range of providers.

This means “there is a risk that all the learning from the collective investigations is not applied consistently”, the board papers said.

A failure to prove at inquests that lessons have been learned from the deaths puts the trust at risk of being criticised by a coroner, which could pose a “reputational risk to the organisation”, the papers said.

The two patients to die of self-inflicted injuries within nine days of each other include a 50-year-old man in the care of the mental health inreach team at HMP Belmarsh, who hanged himself in his cell on 5 February.

The second prisoner to commit suicide was under the care of the mental health inreach team at HMP Swaleside. Early intelligence indicates a likely link to illicit substance misuse, board papers said.

A trust spokeswoman said it could not comment on individual cases, but it has investigated eight of the ten deaths as level 4 serious incidents.

“We did not investigate incidents which had had no input from us as a provider, where the incident investigation was led by another provider or where the death was not unexpected.”

The trust is ”always trying to learn how we can improve our physical care in prisons,” the spokeswoman said.

The trust said it has already changed practice in response to previous incidents, including:

  • Implementing a central referral system for counselling.
  • Revision of observation policy for patients of concern.
  • The review of processes when prisoners do not attend for medication.
  • Improved healthcare screening when prisoners are first admitted to prison.
  • The implementation of medical alert wrist bands to alert clinicians to patients with allergies or pacemakers.

The thematic review of the deaths in custody between 1 April 2016 and 31 March 2017 will be undertaken by the head of patient safety at the trust and presented to the mortality surveillance committee.

Ministry of Justice data launched an internal inquiry into the mental health backgrounds of prisoners who kill themselves after a record high of 119 people died self-inflicted deaths in custody in England and Wales in 2016.

The number of self-inflicted deaths has doubled since 2012.

Self-harming in prisons has also reached a record high of 37,784 incidents in 2016, an increase of 23 per cent from 2015.