1. To issue a final version of the strategy and practice guidance 2. To request implementation of area strategic plans by November 2004. 3. To introduce a new self-harm monitoring sheet.

Probation Circular
REFERENCE NO: 40/2004 ISSUE DATE: 16 July 2004 IMPLEMENTATION DATE: Immediate EXPIRY DATE: July 2009 TO: Chairs of Probation Boards Chief Officers of Probation Secretaries of Probation Boards Chairs of Voluntary Management Committees Approved Premises Managers CC: Board Treasurers Regional Managers AUTHORISED BY: Liz Hill, Head of Public Protection and Courts Unit ATTACHED: Annex A - Strategy, Annex B Practice Guidance, Annex C Guidance in event of incident, Annex D - Monitoring Form

All staff managing, working in, or referring to Approved Premises, should note the contents and timescales of the strategy. Relevant managers should take appropriate action to include: designing and implementing a strategic plan to tackle sudden deaths in approved premises, auditing practice within their approved premises and introducing the monitoring of incidents of self-harm.

PC02/2004 - Deaths of Approved Premises' Residents

John Russell Tel: 020 7217 0772 Fax: 020 7217 0756 E-mail: Colin Pinfold Tel: 020 7217 8226 Fax: 020 7217 0756 E-mail:

National Probation Directorate
Horseferry House, Dean Ryle Street, London, SW1P 2AW General Enquiries: 020 7217 0659 Fax: 020 7217 0660


1 Purpose 1.1 The aim of this strategy and the accompanying practice guidance note is to reduce the numbers of sudden deaths amongst residents of Approved Premises. 1.2 The intended audience for the strategy and guidance include:Probation Boards and Chief Officers; Management Committees of Voluntary Approved Premises; those with senior managerial responsibility for Approved Premises such as Assistant Chief Officers and managers of individual approved premises; staff of Approved Premises; those making referrals to Approved Premises including court staff, bail information officers, staff in prisons, and probation staff in the community e.g. high-risk, public protection and resettlement teams. 2 Background 2.1 The strategy has been developed and implemented so as to make a contribution to the Government’s Health Service strategic plan for the reduction of suicide in the community as set out in the Department of Health’s National Suicide Prevention Strategy for England (2002), which is useful additional reading. 2.2 YEAR 1999 2000 2001 2002 2003 TOTALS Each year, a number of Approved Premises residents lose their lives. Suicide 4 8 3 3 4 22 Overdose 4 13 12 8 3 40 Natural causes 1 2 5 8 3 19 Accident 0 1 2 2 1 6 Total 9 24 22 21 11 87


Whilst some of the deaths are attributable to natural causes, others such as those attributable to accidental drugs overdoses or suicides may be preventable. It should also be borne in mind that evidence shows that those on probation supervision do have a higher incidence of both accidental death and suicide, therefore, residents in Approved Premises may be particularly vulnerable and in need of rapid access to assistance to services such as Samaritans, mental health and drugs services as well as more intensive levels of help and support from Approved Premises staff.

3 DEFINITIONS 3.1 Some sudden deaths can be unintentional, that is when a death occurs without intent to cause harm, for example, the harm which results from recreational drug misuse. For the purposes of this strategy, we adopt the following definition; “Suicide is the intentional act of taking one’s life, either as a result of mental illness or as a result of various other motivations which outweigh the instinct to continue to live.” 3.2 The strategy links together the phenomena of suicide, sudden death, and what might be regarded as ‘potentially preventable deaths’. It does not assume that those that are suicidal will have previously self-harmed, that selfharm is an indicator of a potential suicide or that those who resume significant drug misuse after a considerable period of abstinence (e.g. in custody) which results in sudden death, are offenders who would regard themselves as selfharmers or suicidal. avoided. 4 Principles 4.1 Measuring the impact of any measures to reduce sudden, or potentially preventable deaths, is difficult given that it would involve measuring negative performance indicators. All categories might have an element of interrelatedness but any assumption that there are always strong links should be


Whilst the range of preventative activity might be limited, and the resources available might be restricted, this does not prevent effective action being devised and implemented.

4.3 4.4

This matter is best regarded as a multi-agency and multi-disciplinary subject. There are no models with guaranteed accuracy for assessing the risks of suicide and self-harm.


People that self-harm or are prone to suicidal tendencies may well not be selfharming or suicidal for most of the time.


The strategy will be integrated with forthcoming strategic plans by the National Probation Directorate, for example, the Strategy for Mentally Disordered Offenders, and the Approved Premises and Accommodation Strategy for High Risk Offenders.

5 THE STRATEGY 5.1 This is the first strategic plan devised to reduce deaths of Approved Premises residents. It will be reviewed and evaluated by the National Probation The strategy recognises the need to ensure Directorate in July 2005.

effective flows of information at the referrals, reception and move-on stages including the need to establish a protocol on information sharing between HM Prison Service and the National Probation Service as well as protocols with partner agencies. What the strategy should achieve is: The number of recorded sudden deaths per year in Approved Premises is reduced. Improved and more clearly focused risk assessments of residents. Improved and more clearly focused risk management plans. Access to health and advice services. Increased staff awareness and training in sudden death and self-harm issues. Mandatory local monitoring of instances of self-harm. Learning from experience and innovative practice is integrated into the wider operation of Approved Premises. As far as possible, sudden deaths are avoided.

6 A Strategic Framework for the National Probation Service 6.1 There have been no requirements on the National Probation Service or Approved Premises to have a strategic plan to manage the risks of self-harm or potential suicide amongst offenders. This strategic plan begins to address that position. 6.2 Some Approved Premises will already have a strategy to tackle sudden deaths but these are likely to be centred on individual premises rather than part of a more co-ordinated plan, or indeed, a strategy over all of the Approved Premises within an Area or region. Approved Premises may have developed practices to manage this area of work without the formality of a written policy and some may have been able to provide some degree of staff training. However, a national strategy will consolidate work to date and contribute to greater consistency. 6.3 The strategic framework is ambitious but achievable. It is a starting point for building expertise and sharing best practice. ACTION In order to be able to demonstrate efforts to reduce sudden deaths: 7 The National Probation Directorate will; Follow the interim guidance (issued in PC2/2004 (Deaths of Approved Premises Residents)) with the issue of full guidance to Probation Areas regarding changes to the investigative procedure to be implemented from 1 April 2004, to include what will be required at a local level by the Prisons and Probation Ombudsman’s investigating officer. (Completed). 7.2 The NPD will continue to collect and collate information on deaths investigated by the Office of the Prisons and Probation Ombudsman for feedback to Areas and Ministers. 7.3 Receive and review each report on a death in Approved Premises, consider the implications for the national estate and take appropriate action. (Underway).


Meet with HM Prison Service Safer Custody Group to review the findings and recommendations of reports which have cross-organisation implications.


Continue to be represented at the Ministerial ‘Round Table’ on suicide and self-harm prevention in the criminal justice system.


Continue to be represented on HM Prison Service’s Safer Custody Strategy Steering Group to ensure pan-correctional services liaison.


Support innovation at Area level, in the first instance running a pilot scheme in 13 London approved premises with mobile phones to enable private and swift access to key services such as Samaritans. Subject to the evaluation of the pilot trials in 2004/05 and the resources being available, a nationwide ‘roll-out’ will be considered. (Underway).


Before December 2004, evaluate the feasibility of implementing a pilot scheme of ‘listeners’ to mirror the successful schemes that have developed within prisons.


Before January 2004, commission a literature review of deaths in residential settings, consider the findings and take appropriate action. (Completed publication awaited).


Before August 2004, require all Approved Premises areas to devise and commence implementation of a strategic plan for the reduction of self-harm and sudden death amongst residents. (All Approved Premises within an Area should be integrated within the strategic plan and wherever possible, the strategy should be regional). (Completed).


Before April 2004 produce practice guidance for Approved Premises staff. (Completed). (See Probation Circular 2/2004 (Deaths of Approved Premises Residents) and also annex B to this circular).


Produce reference material to advise staff on the operation of the Coroner’s Court and how to contribute effectively. (Completed).

8 In addition Probation Areas with Approved Premises will: 8.1 Devise a strategic plan to reduce incidents of sudden death in Approved Premises within the Area. If there is more than one Approved Premises the plan will usually be common to all Approved Premises (including those that have voluntary management committees) within an Area. Where possible the strategy should be common to all Approved Premises within a region. Approved Premises with a Voluntary Management Committee are included in the requirement to produce a strategic plan. The plans should be completed before October 2004. 8.2 8.3 Implementation of the plan should have commenced by November 2004. Part of the plan should demonstrate the arrangements for staff development and staff training, including First Aid and emergency treatment training and refresher courses. 8.4 The plan should be compatible with other strategic plans for example, Drug Action Team plans to reduce deaths by drug misuse. 8.5 By January 2005, devise and implement systems that are common to all Probation Board or Voluntary Committee managed Approved Premises within an Area (and ideally within a region) to record significant incidents of selfharm. (See Annex D of this Circular for sample monitoring form). 8.6 Approved Premises managers should have in place systems to review each incident of self-harm and the implications for the supervision of the case but also to consider the implications for training, regime or policy that might reduce incidents, or contribute to greater safety. 8.7 As part of the local plan Approved Premises managers might consider nominating a member of supervisory staff team as Suicide Prevention Coordinator, given the positive impact that SPCs have had within prisons on practice improvements, liaison and consistency, and raising the profile of active prevention of deaths. 8.8 Consideration should be given to including representation within each Probation region at ACO level (normally an ACO with responsibility for

Approved Premises) on the HM Prison Service Area Suicide Prevention Forum meetings with a view to a joint approach on areas of common interest. 9 Evaluation 9.1 The content and effectiveness of the strategy will be evaluated by the National Probation Directorate in July 2005.

July 2004

This checklist is to be used as an audit tool to ensure that good practice is in place - or that steps are being taken to introduce such good practice - to prevent sudden deaths of approved premises residents. For each required action the form asks for the name of the lead person from each approved premises who will ensure that the action is implemented, and has a space for a date to show that work is underway to implement each action, and another space to show that work has been completed on each action point.


1.1 REFERRALS Ensure that for each referral there are systems in place to: 1. Establish whether there is any evidence that the person being referred has previously been suicidal. LEAD PERSON UNDERWAY COMPLETED

2. If currently in custody, to establish whether there is any history of F20/52 SH or ACCT registration in accordance with HM Prison Service procedures when a ‘risk of self-harm or suicide’ has been identified. LEAD PERSON UNDERWAY COMPLETED

3. Ensure that the approved premises referrals officer is able to obtain any current or previous F20/52 SH or ACCT. LEAD PERSON UNDERWAY COMPLETED

4. Ensure that checks are undertaken for other indicators of vulnerability to suicide or sudden death. LEAD PERSON UNDERWAY COMPLETED

5. Ensure that checks are undertaken to confirm if the person is currently receiving treatment or medication and, if so, what it is. LEAD PERSON UNDERWAY COMPLETED

1.2. PRE-ADMISSION Ensure that before admission, arrangements are in place: 1. To ensure the safe transition from custody to admission in the Approved Premises. LEAD PERSON UNDERWAY COMPLETED

2. For an assessment to be made to see if allocation to a single or a shared room would assist in containing or reducing risk. LEAD PERSON UNDERWAY COMPLETED

3. That in relevant cases the suitability of any other shared room occupant is assessed. LEAD PERSON UNDERWAY COMPLETED

4. That the advantages of allocation of a particular room (e.g. in close proximity to the
main office) are assessed. LEAD PERSON UNDERWAY COMPLETED

5. That consideration is given to pairing the new admission with an existing trustworthy resident (Buddy scheme) to assist in reducing or managing risk. LEAD PERSON UNDERWAY COMPLETED

6. That the resident’s needs are assessed for access to any specialised services and, where necessary, arrangements can be put into place in advance of admission. LEAD PERSON UNDERWAY COMPLETED

7. There is access to a GP in place. LEAD PERSON UNDERWAY COMPLETED

1.3. ADMISSION AND INDUCTION Ensure that there are systems in place to ensure that: 1. Staff who will be on duty are briefed to expect vulnerable residents on their first day. LEAD PERSON UNDERWAY COMPLETED

2. Details about Samaritans and other similar organisations are available in residents’ induction packs and on residents’ notice boards. LEAD PERSON UNDERWAY COMPLETED

3. The dangers of substance misuse and warnings about the dangers of resuming drug misuse after a period of abstinence are included in induction packs. LEAD PERSON UNDERWAY COMPLETED

4. Each resident is clear about ‘points of help’ from within the approved premises and in the wider community. LEAD PERSON UNDERWAY COMPLETED

5. There are detailed risk of self-harm/suicide assessments and plans to manage the identified risks in each relevant case. (The plan must include who is going to do what and why as well as what the contingency or follow-on action should be. It should address any ‘warning indicators’ that have been identified in the assessment). LEAD PERSON UNDERWAY COMPLETED

6. Such plans available to all staff from the day of admission. LEAD PERSON UNDERWAY COMPLETED

1.4. DURATION OF PERIOD OF RESIDENCE Ensure that it is clear that: 1. All staff can identify any resident assessed as being at risk, what the risk assessment is, and what the details of the risk management plan are. LEAD PERSON UNDERWAY COMPLETED

2. The specific actions identified in the risk management plan are allocated to specific members of staff for them to carry them out. LEAD PERSON UNDERWAY COMPLETED

3. Risk of self-harm or sudden death management plans are reviewed with all relevant staff and other parties. LEAD PERSON UNDERWAY COMPLETED

4. It is always clear in risk management plans exactly what will be done to contain or reduce risks of self harm or sudden death, what factors may increase the risk and what will be done to prevent escalation. LEAD PERSON UNDERWAY COMPLETED

5. Identifying features and next of kin details always satisfactorily recorded. LEAD PERSON UNDERWAY COMPLETED

6. Potentially serious allergies are recorded and acted upon appropriately. LEAD PERSON UNDERWAY COMPLETED

1.5. DEPARTURE Ensure that systems are in place to ensure that: 1. Information about risk of self-harm or sudden death would be passed to other agencies or organisations in the event of a request for recall, breach or planned departure. LEAD PERSON UNDERWAY COMPLETED

2. When appropriate, there would be a plan to manage the risks of self-injury or potential fatality during the transition between the Approved Premises and the ‘moveon’ location. LEAD PERSON UNDERWAY COMPLETED

2. MANAGEMENT ISSUES 2.1 APPROVED PREMISES ENVIRONMENT Ensure that arrangements are in place to: 1. Ensure that the building is regularly assessed, possibly as part of routine ‘health and safety’ checks, to identify possible adverse design features. (Ligature points, lack of safety-glass in glazed areas etc.). LEAD PERSON UNDERWAY COMPLETED

2. Check if there are any infrequently used or unsecured outbuildings which present opportunity and risk that are not regularly checked or have not been made secure. LEAD PERSON UNDERWAY COMPLETED

3. Give consideration to installing blue ‘anti-injection’ lighting in bathrooms and toilets. LEAD PERSON UNDERWAY COMPLETED

4. Ensure that kitchen knives and other sharp utensils and any tool-kits are kept in secured areas and systematically accounted for. LEAD PERSON UNDERWAY COMPLETED

5. Check if there is sufficient discreet visibility into communal areas. LEAD PERSON UNDERWAY COMPLETED

6. Ensure that medication is kept in accordance with Approved Premises practice guidance, including good recording systems for issue and checks are made to ensure that medication has been issued to the resident in accordance with the prescription. LEAD PERSON UNDERWAY COMPLETED

7. Check that there are first aid/resuscitation packs at principal points around the premises/or routinely carried by all supervisory staff. LEAD PERSON UNDERWAY COMPLETED

8. Ensure that there is good access to telephone and contact addresses for those organisations who could offer a potential service to relevant residents. LEAD PERSON UNDERWAY COMPLETED

2.2 STAFF TRAINING AND AWARENESS Ensure that arrangements are in place to: 1. Give consideration to the feasibility of appointing a Suicide Prevention Co-ordinator within each Approved Premises team to ensure that the issues of sudden death remain a priority and there is a central point for learning. LEAD PERSON UNDERWAY COMPLETED

2. Check that this matter is included as part of new staff induction. LEAD PERSON UNDERWAY COMPLETED

3. Ensure that sudden death issues are included in staff training plans or in individual staff members development plans. LEAD PERSON UNDERWAY COMPLETED

4. Ensure that there are routes to ensure that practice ideas and learning from all Approved Premises within the region are shared. LEAD PERSON UNDERWAY COMPLETED

5. Ensure that there are ‘advisory’ links with other professionals (CPN/ SPCs in prisons, Samaritans etc.), to give general advice to the Approved Premises team or specific case advice. LEAD PERSON UNDERWAY COMPLETED

6. Ensure that all staff are aware of those residents statistically most at risk and the statistically most ‘at-risk’ periods. LEAD PERSON UNDERWAY COMPLETED

7. Ensure that there is a staff-training plan for first aid and emergency treatment and ‘refresher’ training. LEAD PERSON UNDERWAY COMPLETED

8. Give consideration to the feasibility of running training exercises or ‘practice runs’ to build staff confidence and ensure staff are familiar with procedures. LEAD PERSON UNDERWAY COMPLETED

2.3 STRUCTURES AND SYSTEMS 1. Ensure that there is an Approved Premises strategic plan for the prevention of sudden death and that this is compatible or shared across all Approved Premises within the Area (and ideally within the region). LEAD PERSON UNDERWAY COMPLETED

2. Ensure that referring staff are aware of the strategic plan. LEAD PERSON UNDERWAY COMPLETED

3. Ensure that there are systems in place to ensure that those most at risk can be (discretely) identified by all staff. LEAD PERSON UNDERWAY COMPLETED

4. Ensure that there are arrangements in place to ensure that the whole of the building and relevant out-side space is routinely checked several times a day every day of the week, including during the night, and that when this has been done it is accurately recorded in the log. LEAD PERSON UNDERWAY COMPLETED

5. Ensure that as part of the Leadership task, managers demonstrate that Sudden Death Prevention is an important element of any well-managed, well-run Approved Premises. LEAD PERSON UNDERWAY COMPLETED

6. Ensure that there are systems in place to record serious incidents of significant selfharm and other events where a fatality might have occurred. LEAD PERSON UNDERWAY COMPLETED

7. Ensure that the above incidents receive a review to take the opportunity of recognising good practice and identifying areas for improvement or change. LEAD PERSON UNDERWAY COMPLETED

8. Ensure that there are structures in place to ensure that the Public Protection and Courts Unit of the National Probation Directorate and the Office of the Ombudsman are notified of a death and given all relevant details and thereafter kept informed of key developments. LEAD PERSON UNDERWAY COMPLETED

(Note that this is a general guide. More detailed instructions tailored to the individual circumstances and staffing arrangements are desirable) If there is an event on-site of serious self-harm or sudden death: • Call an ambulance. • If an obvious serious attempt at suicide or an obvious fatality call police. • Every possible effort should be made to save life in accordance with the limited skills of approved premises staff in first-aid and resuscitation techniques. • Do not leave resident unattended unless absolutely unavoidable. • Staff must be aware of own safety (bodily fluids and physical dangers such as electricity and glass). • Keep the area as free as possible from other residents and unnecessary staff. • Take any advice of paramedics or police. • If GP certifies death, police will notify next of kin. • Seal the area and take police advice on securing the personal belongings of the deceased. • Notify on-call manager, Assistant Chief Officer as soon as practicable. If a death has occurred: • ACO to notify Chief Officer, Chair of Board, and Public Protection and Courts Unit at the National Probation Directorate and also ensure Ombudsman’s Office has been notified and the local PR officer. • Details of incident should be recorded on the case file/log as appropriate to include when the resident was last seen. • All members of staff are advised to make their own personal notes of the sequence and timing of the events for future reference if required. • Police may require statements by staff and residents – have an office or space available for this, with refreshments if possible and retain a copy of statements made. • Emotional and physical well-being of other residents and staff should be attended to. • Notify any other staff members (especially in other teams, or approved premises staff at home in some cases as necessary). Inform Probation Victim Liaison if appropriate. • Assess any damage to premises and arrange repair or take any necessary measures in the interests of safety. • All electronic and paper files on resident to be made secure. • Two members of staff, or Approved Premises member of staff and police officer to pack residents belongings – record contents – and keep securely. • If family visit ensure that there are arrangements to see them in privacy and be aware that they may wish to see the resident’s bedroom or the scene of the death. • The police will have arrangements with undertakers to remove the deceased from the building. The funeral directors address and contact details should be recorded for easy access to inform the family or any other enquiry. • It is not appropriate for the family to view the deceased at the Approved Premises.

• • • •

• • •

• •

Be prepared on issues of confidentiality when family visit, especially if they were previously estranged. Take some sensitive steps to ensure identity before possessions are released. All Approved Premises should already have contacts for faith and community leaders in the area and such people might give helpful advice on customs and expectations as well as being present if the family visit. Careful consideration should be given to the release of possessions. Never hand over property in carrier bags or bin-liners. Clothes should be laundered and neatly parcelled, discretion used on the disposal of perishable items, pornography, etc, and families advised on any potentially upsetting contents such as unsent letters or cards. Consideration should be given to what may need to be done to achieve any changes to an area of the building before it is re-opened or rooms reallocated. It is not unusual for the inquest to be opened and then adjourned in order that the body can be released for burial. Attendance at the funeral will be a matter of judgement in each case. It might be that seeking the family’s approval to send a representative would be appropriate in some cases. In others, staff should be aware that they may be the only attendees at the service. ACO should write to Coroner’s office requesting notification of the date, time and place of the inquest. Prepare for the Inquest: ensure knowledge of procedure, identify who will attend, decide which documents and records should be taken to the Court and by whom (although it is useful to prepare a brief summary of all the key information such as dates and reason for admission). It is useful to ensure there is some media statement in reserve in the event of a press enquiry. Prepare for the visit of the Ombudsman’s Investigator: liaise with the Ombudsman’s Office about requirements, ensure availability of all assessments, records, and files including electronic files, as well as copies of staff statements. Staff availability, office/interviewing space, keys, information to staff and residents where appropriate. Advise the NPD and the Ombudsman’s Office in writing of the verdict.

Attached is a self-harm monitoring form. This must be completed in all cases where staff become aware that a resident of an approved premises has deliberately harmed themselves. One copy of the completed form should go on to the resident's file. Another copy should be filed separately and these completed forms should be collated and discussed at team meetings. This should be a regular agenda item at team meetings, so that any trends can be quickly identified, and appropriate action taken.

Self-Harm is any act where a resident deliberately harms themselves irrespective of method, intent or severity of any injury. Noose/ligature making should also be reported. Anorexia, Bulimia Nervosa or food refusal should not be reported on this form. Staff should report all incidents that they are aware of.

Approved Premises: ……………………………………………. Resident: ………………………………… Gender: M/F ……… Ethnic Origin:…………………………………………………… Age Range: Under 20 20-30 31-40 41-50 51-60 61+ Order Type: Licence Community order Bail Other (Please specify if other) .………………………………………... Reporting Staff: ………………………………………………… Date of Report: …………………………………………………. 1. Accommodation
1.1 1.2 1.3 Annex or cluster Shared room no other occupant Shared room with other occupant

7. Self-poisoning / Overdose Substances / Swallowing
7.1 7.2 7.3 7.4 7.5 7.6 7.7 Own Medication Other person’s medication Illegal drugs Cleaning materials Razor Blades Batteries Other specify: ………………………………..

2. Time of Incident
2.1 2.2 2.3 2.4 2.5 7am to 11am 11am to 7pm 7pm to 11pm 11pm to 7am Not known

8. Required treatment as
8.1 8.2 Outpatient Inpatient

3. Period of residence
3.1 3.2 3.3 3.4 3.5 3.6 Within one week of admission Within two weeks of admission Within three weeks of admission Within four weeks of admission After four weeks of admission Within one month of planned departure

9. Was Resuscitation required?
Yes No

10. Was treatment administered by:
10.1 10.2 10.3 10.4 10.5 Resident Duty staff GP Paramedics/Ambulance No treatment

4. Was the incident prior to an imminent court appearance?
Yes No

5. Place of Incident
5.1 5.2 5.3 5.4 5.5 Resident bedroom Communal area Outside of the building Toilet or bathroom area Other

11. Self-harm Assessment -Was Resident:
11.1 11.2 11.3 11.4 Un-assessed for self-harm Assessed, but not assessed as risk of self-harm Assessed as risk of self-harm but no management plan in place Assessed as risk of self-harm and plan in place to manage

6. Self Harm Method
6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 6.9 6.10 Cutting or scratching Self poisoning Burning Swallowing objects Head banging – wall-punching Suffocation Wound aggravation Strangulation Hanging Other (specify below)

12. Follow up action …………………………………………… …………………………………………… 13. Approved Premises Manager comments …………………………………………… …………………………………………… ……………………………………………

……………………………………… ………………………………………