DEATHS OF APPROVED PREMISES' Probation

RESIDENTS
PURPOSE
Circular
1. To advise staff that with effect from 1 April 2004 the Prisons and REFERENCE NO:
Probation Ombudsman will investigate all deaths of approved
02/2004
premises' residents (as well as deaths in prison custody) and to give
staff initial details of how we envisage this working in practice.
ISSUE DATE:
2. To issue, for consultation, a draft strategy on reducing deaths (Annex
6 January 2004
B) and a practice guidance note (Annex C).

IMPLEMENTATION DATE:
ACTION
1. Please could all Probation Boards, Chief Officers, Voluntary Immediate
Management Committees and Approved Premises Managers note this
change and ensure that all relevant staff are prepared for this new EXPIRY DATE:
process. January 2009
2. We would be grateful for comments and feedback on the draft strategy
by 27 February 2004. TO:
Chairs of Probation Boards
SUMMARY Chief Officers of Probation
Ministers have decided that with effect from 1 April 2004 the Prisons and Secretaries of Probation Boards
Probation Ombudsman will investigate all deaths of approved premises' Chairs of Voluntary Management
residents, whether probation board managed approved premises or voluntary Committees
managed approved premises. In practice this will mean that Assistant Chief Approved Premises Managers
Officers will no longer have to complete management reviews for NPD, but all
other procedures should remain in place as now. CC:
Board Treasurers
RELEVANT PREVIOUS PROBATION CIRCULARS Regional Managers
This circular replaces PC51/2002 in part.
AUTHORISED BY:
CONTACTS FOR ENQUIRIES
Liz Hill, Head of Public Protection
John Russell
Unit
Tel: 020 7217 0772 Fax: 020 7217 0756
E-mail: JohnFyfe.Russell@homeoffice.gsi.gov.uk
ATTACHED:
Annex A - Background on PPO
Colin Pinfold
Tel: 020 7217 8226 Fax: 020 7217 0756 Annex B - Draft Strategy
E-mail: Colin.Pinfold2@homeoffice.gsi.gov.uk Annex C - Practice Guidance
Note

National Probation Directorate

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

Enforcement, rehabilitation and public protection

BACKGROUND

1. At present, when an approved premises' resident dies, a management review is carried out by the local Assistant
Chief Officer with responsibility for approved premises. This process, while valuable, is not seen as being truly
independent, either by families of residents who die, or by Home Office Ministers. Ministers have therefore decided that
with effect from 1 April 2004, the Prisons and Probation Ombudsman will have the responsibility of investigating the death
of an approved premises resident. This circular cannot provide a detailed explanation of how this new process will work,
but will set out in general terms some of the practical arrangements that will need to be put in place.

2. The Prisons and Probation Ombudsman is not yet a statutory appointment, and so he will be undertaking this
work on an administrative basis. Having the Ombudsman's Office investigate deaths will not meet the requirements of
Article 2 ECHR, which requires that investigations into a death where the State may carry some responsibility for the
events in question must be independent, effective, reasonably prompt, have a sufficient element of public scrutiny and
involve the next of kin. However, we believe that this change will bring with it a number of important advantages and
improvements to our current system of investigating deaths of approved premises' residents. The current system means
that an Assistant Chief Officer has to interview staff, of whom they may be the direct line manager, about a very traumatic
incident, while at the same time offering support to those same staff. ACOs will now no longer have to do an investigation
for the National Probation Directorate. The Ombudsman will have experienced investigating teams, who will be well
aware of the sensitivities of these traumatic incidents, and will deal with staff accordingly. The Ombudsman's reports will
be seen as rigorous and for all practical purposes independent, and so will be able to provide assurance to the families of
deceased residents. The reports will also be of a more consistent format, and so will enable learning to be collated and
formulated more easily. All the reports will be likely to have recommendations, which the Ombudsman will expect the
National Probation Service to put in place as soon as practicable. Ultimately, we hope that strengthening investigations
into deaths will lead to a reduction in the number of these tragic events, and this can only be good for us all.

PRACTICAL DETAILS
3. In practice, nothing will change - except that instead of the ACO preparing a management review for NPD, the
Prisons and Probation Ombudsman will prepare an investigation report. We would stress that probation boards and
voluntary management committees should continue to ensure that approved premises are maintained in as safe a
condition as possible, in accordance with Regulation 8 of the Approved Premises Regulations 2001. The process of
external investigation should not prevent managers taking any action they regard as appropriate. We would also urge all
staff involved in approved premises to continue to have suicide and self-harm prevention amongst residents as a very
high priority. However, it may be helpful to give a couple of examples of how the new process should work in practice;

Example One

A current resident of an approved premises is found dead in a local park, and police phone the approved premises
manager and let them know. In this case, the SPO Manager should first contact the ACO. It is also good practice for the
ACO to notify the Chief Officer and the Chair of the Board, or the Chair of the voluntary management committee. Within
24 hours, or sooner if possible, a senior manager must notify the Prisons and Probation Ombudsman by telephone that
an approved premises' resident has died. This can be done by the SPO, but it will remain the responsibility of the ACO to
make sure that someone has informed the Ombudsman. Within a maximum of 48 hours, or earlier if necessary, the
Approved Premises Section of the National Probation Directorate must be notified, as set out in Probation Circular
PC51/2002. We wish to make it clear that NPD would require earlier notification if there was a possibility of adverse
publicity, in high profile cases. In these cases, if you need to contact NPD at the weekend, please phone the Home
Office duty officer (020 7222 8561 or 8562), who will be able to pass a message on to the Head of Public Protection Unit.
For the sake of clarity, we need to have the following details;

• Name of resident, gender, date of birth, ethnic origin

• Date of death
• Status (bailee, licencee, community sentence, voluntary resident, or ROTL etc). This should also include a note of
the date of admission of the resident, and a note of the date when the resident was due to leave the approved
premises
• Offence/alleged offence
• Circumstances of death – This should include where and how and when the body was found, when was the last time
the resident was seen alive, did the resident seem well when last seen, if it was a drug overdose any initial indication
of the method of drug use, was curfew check carried out in full the previous night, were there any previous indications
of suicide or drug misuse etc, etc.
• Any media interest in the case
• Next of kin, and an indication whether they have been informed
• An indication of whether you received relevant information on self-harm (such as information about possible F2052SH
procedures or the existence of psychiatric reports) from the prison or court.

PC02/2003 - Deaths of Approved Premises' Residents 2

• An indication of whether or not the relevant parts of OASys concerning self-harm were fully completed.

There will no longer be a requirement for the ACO to complete a management review for NPD, as set out in Paragraphs 5
and following, of Probation Circular PC51/2002.

All other issues, including the possibility of the involvement of the Coroner, will be dealt with as normal. The SPO or ACO
will liaise with the deceased's family and make arrangements for the collection of belongings (if and when the police have
approved release) and so on, and the Ombudsman will conduct an investigation, and produce a report.

Example Two

A resident is found in his room, possibly dead or dying, at about 11pm. Staff will immediately phone the emergency
services as normal. Staff will also contact the duty SPO. Once police have attended and death has been confirmed by
the GP, the Prisons and Probation Ombudsman must be notified by phone as soon as possible. As noted above, it will
be the responsibility of the ACO to make sure that this has been done. The Public Protection Unit of NPD must be
notified within 48 hours, or earlier, as set out above.

A full record must be kept on the case file (and log if appropriate). It is good practice for staff to keep a copy of any
statements that they give to police.

When a death occurs at an approved premises, each member of staff should individually write down a note, in their own
words, of exactly what happened, as soon as possible after the event, for future reference.

Again, the Ombudsman will conduct an investigation, by reviewing all relevant papers and interviewing staff, and produce
a report. In effect this report will have "multiple customers". A copy will be for the Coroner, one for us in NPD, one for the
local probation area, and one for the family of the deceased, if the Coroner agrees that the family should be given a copy
of the report.

OTHER CONSIDERATIONS
4. We would ask all staff to fully co-operate with these new procedures, whether staff employed by a local probation
board, or a voluntary management committee, or indeed any other partnership staff who the Ombudsman's investigating
team may wish to speak to. The Ombudsman will also need to have copies of all relevant documents, including papers
from the resident's file and case records and relevant sections of the logbook etc. Staff should fully co-operate with all
requests from the Ombudsman's investigating team. The Ombudsman is doing this work on behalf of the Home
Secretary, and we know that these new procedures will be of benefit to us all, as explained above.

5. Discussions are continuing about how public the Ombudsman's reports will be. As noted above, it is likely that,
with the agreement of the Coroner, the family of the deceased will be given a copy of the report. The family will be asked
to keep the contents of the report confidential, at least until after the Coroner's inquest has been held. It would be good
practice to notify your PR section that such a report has been given to the family, so as to be ready for any media
enquiries about this should they ensue. The Ombudsman also has to submit an annual report on his work to Parliament
and will obviously refer to the investigation work into deaths in his annual report.

CONCLUSION
6. Please find attached to this circular at Annex A a background briefing note on this work. Further details, such as
the phone number for the Ombudsman etc, will be announced in a further probation circular as soon as possible. The
current contact details for the Ombudsman are set out in Paragraph 7 below, but there may well be a special telephone
number etc. set up for this work. The Ombudsman's Office will be expanded to take on this new work, and posts will be
advertised during January.

7. The current contact details for the Prisons and Probation Ombudsman are as follows -

The Prisons and Probation Ombudsman

Third Floor
Ashley House
2 Monck Street
London SW1P 2BQ

Tel: 020 7035 2876

Fax: 020 7035 2860

PC02/2003 - Deaths of Approved Premises' Residents 3

DRAFT STRATEGY AND PRACTICE GUIDANCE NOTE
8. Also attached to this circular at Annex B for consultation is a draft strategy on reducing deaths of approved
premises' residents. This has been produced following consultation with a sub-group of the Hostels and Offender
Housing CLAN. We would be grateful for comments and feedback on this draft document. It would be helpful to receive
responses by 27 February 2004. We have commissioned the University of Central England to do a literature search for
us on deaths of hostel residents, and by this time we hope to have received their report and recommendations, which will
also help us to finalise the strategy.

9. We also enclose, at Annex C of this circular, a Practice Guidance Note on reducing sudden deaths of approved
premises' residents.

PC02/2003 - Deaths of Approved Premises' Residents 4

 ANNEX A
THE PPO'S NEW ROLE

From 1 April 2004 the PPO will investigate all deaths of prisoners and probation hostel (approved premises) residents,
whatever the apparent cause. He will also investigate any deaths of those held in immigration detention accommodation.

TERMS OF REFERENCE FOR INVESTIGATIONS

The PPO will assist in the development of standard terms of reference, which will include:

- establishing the circumstances and events surrounding the death;

- examining whether any change in operational methods, policy, practice or management arrangements would help
prevent a recurrence;
- providing explanations and insight for the bereaved families.

PROCEDURE

The PPO will act on notification of a death from the relevant Service. He will decide on the level of investigation required.
He will be able to obtain expert advice where necessary. He will develop protocols governing the conduct of the
investigation in respect of the Services and the family of the deceased, so as to maximise the involvement and co-
operation of all who can contribute. He will liase closely with (among others) the police regarding any criminal
investigation and the Coroner regarding the inquest process. He will establish a joint approach with the NHS to ensure
appropriate investigation of clinical matters. He will be able to recommend that a disciplinary investigation be undertaken
by the relevant Service if appropriate.

POWERS

The PPO does not yet have statutory powers to compel co-operation with his investigations. Prison Service staff are
expected to co-operate in accordance with the terms and conditions of their employment. The Coroner will remain able to
compel attendance at the inquest.

REPORTS

The PPO will normally report on the investigation to the Home Secretary, the relevant Service, the family and the
Coroner, and make recommendations as appropriate. The nature and extent of any wider publication will be a matter for
the Coroner in the first instance and, when the inquest is finished, the PPO. The PPO will not as a matter of routine
publish individual investigation reports – he will need to respect the confidentiality of those involved, in particular the
family of the deceased. He will be able to include summaries in his annual report to the Home Secretary and Parliament,
and to publish special reports where the public interest requires that. There will be no restrictions on the family’s use of
the report, except to the extent necessary to avoid prejudicing the inquest.

RECOMMENDATIONS

The Services will be expected to implement the PPO’s recommendations. We are exploring with Her Majesty’s
Inspectors of Prisons and Probation a possible role for their offices in helping to ensure that that is done satisfactorily.

STAFFING

The PPO will recruit a substantial number of additional investigating staff for this work. The PPO hopes to draw staff from
his own office, the Prison and Probation Services, the Home Office and other government departments, other
ombudsman offices, and external competition, for full or part-time employment and secondment. He will seek to achieve
the right mix of demonstrable independence with experience of the custodial services. He aims to second existing
Service investigators to assist with the transition and in the event of unforeseen demand. (This model has worked
successfully in recent one-off PPO death investigations at Styal and Manchester prisons, although the need for it will
diminish as the PPO’s new team is established.)

PC02/2003 - Deaths of Approved Premises' Residents 5

COST

The estimated cost of the new arrangements is £1.5 - 2m a year. That will be provided from existing Home Office
resources.

POLICY COMMITMENT

The White Paper “Justice for All” said (6.39):

“The Ombudsman for Prisons and Probation has an important role in providing independent adjudication of
individual cases. At present this is an administrative Home Office appointment. We feel that such a critical
appointment should have a clear statutory basis and we will legislate to achieve this as soon as possible. At
the same time we are considering giving the Ombudsman power to investigate suicides.”

Work on the White Paper commitments has been taken forward by a dedicated team in the Home Office, with full
involvement of the PPO's office and other key players across government. We have conducted a targeted public
consultation exercise which included a seminar on 10 June 2003 attended by more than 50 interested parties. There was
broad support for the proposals, although there remain a number of complex practical issues to resolve.

A statutory basis for death investigation by the PPO will require careful consideration in the light of proposals for reform of
the Coroner system which Ministers are currently considering, and of developing case law in relation to Article 2 of the
European Convention on Human Rights. We do not see that as a reason to delay improvements to the investigation of
deaths in custody which the involvement of the PPO is expected to deliver.

PC02/2003 - Deaths of Approved Premises' Residents 6

ANNEX B

NATIONAL PROBATION SERVICE STRATEGY FOR PREVENTING SUDDEN DEATHS IN

APPROVED PREMISES

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;
‰ those with managerial responsibility for Approved Premises such as Assistant Chief Officers and
managers of individual hostels;
‰ staff of Approved Premises;
‰ those making referrals to Approved Premises including court staff such as bail information officers, staff
in prisons, and probation staff in the community e.g. the attendant teams, and from partner
agencies.

2 BACKGROUND

2.1 The strategy must be 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 Each year, a number of Approved Premises residents lose their lives. The table below gives details for
the last 5 years.

YEAR Suicide Overdose Natural causes Accident Total

1999 4 4 1 0 9
2000 8 13 2 1 24
2001 3 12 5 2 22
2002 3 8 8 2 21
TOTALS 18 37 16 5 76

2.3 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 general 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;

PC02/2003 - Deaths of Approved Premises' Residents 7

 ‘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’ for the sake of expediency. It does not assume that those that are suicidal will self-harm, that
self-harm is an indicator of a potential suicide or that those who resume significant drug misuse after a
considerable period of abstinence (in custody) which results in sudden death, are offenders who would regard
themselves as self-harmers or suicidal. All three categories might have an element of inter-relatedness but any
assumption that there are always strong links should be 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.

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

4.3 This matter is best regarded as a multi-agency and multi-disciplinary subject.

4.4 There are no guaranteed effective models for assessing the risks of suicide and self-harm.

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

4.6 The strategy will be integrated with forthcoming strategic plans by the NPD, for example, with regard to 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. It will be reviewed and evaluated by the National Probation Directorate.
The strategy concerns the need to ensure effective flows of information at the referrals and reception
and move-on stages including the need to establish a [national] protocol on information sharing
between prison service and NPD along with protocols with partner agencies. What the strategy should
achieve is:
‰ 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;
‰ improved local monitoring of instances of self-harm;
‰ learning from experience and innovative practice is integrated into the wider operation of Approved
Premises;

PC02/2003 - Deaths of Approved Premises' Residents 8

 ‰ sudden deaths are avoided;
‰ The number of recorded sudden deaths per year in Approved Premises is reduced.

6 A STRATEGIC FRAMEWORK FOR THE NATIONAL PROBATION SERVICE

6.1 At the present time there are no requirements on the NPS or Approved Premises to have a strategic
plan to manage the risks of self-harm or potential suicide amongst offenders.

6.2 Some Approved Premises will have a strategy but they are likely to be centred on individual premises
rather than part of a more coordinated 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 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.

ACTION

In order to be able to demonstrate efforts to reduce sudden deaths:

7 The National Probation Directorate will;

7.1 issue full guidance to all Probation Areas if the anticipated change of
the investigative procedure is implemented.

7.2 if deaths in Approved Premises are to be investigated by the Ombudsman’s Office, the NPD will
continue to collect and collate information on incidents for feed-back to Areas.

7.3 by April 2004, produce a programme to facilitate good practice through the CLAN meeting, NAPBH
meeting, NPD newsletters and correspondence.

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

7.5 Continue to be represented on HMPS Safer Custody Strategy Steering Group to ensure pan-
correctional services liaison.

7.6 Support innovation at Area level, in the first instance running a pilot scheme to commence in 2003 in
13 London hostels with DECT phones to enable private and swift access to key services such as
Samaritans. Subject to the evaluation of the pilot trials in 2004 and the resources being available, a
nationwide ‘roll-out’ will be considered.

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

7.8 before January 2004, commission a literature review of deaths in residential settings, consider the
findings and take appropriate action.

7.9 Continue to assist with the development of the arrangements which may result in deaths in Approved
Premises being independently reviewed by the Ombudsman.

7.10 Before April 2004, require all Approved Premises areas to devise and implement a strategic plan for
the reduction of self-harm and suicide amongst residents.

7.11 before April 2004 produce practice guidance for Approved Premises staff.

7.12 Before April 2004 produce reference material to advise staff on the operation of the Coroner’s Court

PC02/2003 - Deaths of Approved Premises' Residents 9

 and how to contribute effectively.

8 In addition relevant Probation Areas 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
within an Area. Where possible the strategy should be common to all Approved Premises within a
region. Copies of the plans will be sent to the Approved Premises section of the Public Protection Unit
NPD. Approved Premises with a Voluntary Management Committee are included in the requirement to
produce a strategic plan.

8.2 implement the above plan from 1 April 2004.

8.3 demonstrate as part of the plan the arrangements for staff development and staff training.

8.4 Prior to April 2004, devise systems which are common to all Approved Premises within an Area (and
ideally within a region) to monitor significant incidents of self-harm (and possibly death ‘near misses).

8.5 As part of the local plan approved premises managers might consider nominating a member of staff as
Suicide Prevention Coordinator given the impact that SPCs have had within prisons on practice
improvements, liaison and consistency, and raising the profile of deaths in custody.

8.6 Liaison should take place to see if it would be appropriate for representation within each probation region
at ACO level (normally an ACO with responsibility for Approved Premises) on the Area HM Prison
Service Suicide Prevention Forum meetings - to commence from April 2004, with a view to a joint
approach in addressing areas of common interest.

9 Evaluation

9.1 The content and effectiveness of the strategy will be evaluated by the National Probation Directorate.

PC02/2003 - Deaths of Approved Premises' Residents 10

 ANNEX C

PREVENTION OF SUDDEN DEATHS IN APPROVED PREMISES

PRACTICE GUIDANCE

CASEWORK ISSUES

REFERRALS

Is there any evidence that the person referred has previously been suicidal?
If currently in custody, is there any history of F2052SH registration in accordance with HM Prison Service procedures
when a ‘risk of self-harm or suicide’ has been identified?
If currently or previously F2052SH obtain full details.
Are there other indicators of vulnerability to suicide or sudden death?
Is the person currently receiving treatment or medication?

PRE-ADMISSION

What arrangements need to be made to ensure the safe transition from custody to admission in the Approved Premises?
Would allocation to a single or a shared room assist in containing or reducing risk?
Screen for suitability of any other shared room occupant.
Would the allocation of a particular room (e.g. in close proximity to the main office) be an advantage?
Would pairing the new admission with an existing trustworthy resident (Buddy scheme) assist in reducing or managing
risk?
Will the resident need access to any specialised services and if so can this be arranged in advance?
Will access to a GP be in place upon admission?

ADMISSION AND INDUCTION

Are the staff who will be on duty briefed to expect the resident on the first day?
Are details about Samaritans and other similar organisations available in the resident induction pack?
Are details about dangers of substance misuse and warnings about the dangers of resuming drug misuse after a period
of abstinence included in the induction pack?
Is the resident clear about ‘points of help’ within the approved premises and within the community generally?
Is there a detailed risk of self-harm/suicide assessment and a plan to manage the identified risks? (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). Will the plan be available to all staff from the day of
admission?

DURATION OF PERIOD OF RESIDENCE

Are there structures to enable all staff to identify the resident as being at risk, what the risk assessment is, and the details
of the risk management plan?
Are there clear arrangements to review the risk management plan with all relevant staff and other parties?

DEPARTURE

Has information about risk been passed to other bodies in the event of a request for recall, breach or planned departure?
Is this recorded?
When appropriate, is there a plan to manage the risks of self-injury or potential fatality during the transition between the
Approved Premises and the ‘move-on’ location?

MANAGEMENT ISSUES

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APPROVED PREMISES ENVIRONMENT AND REGIME

Does the building have a cheerful and well-cared for ambience?

Are some of the bedrooms of a brighter aspect than others?
Is the building regularly assessed, (environmental auditing) possibly as part of routine ‘health and safety’ checks, to
identify possible adverse design features? (Ligature points, lack of safety-glass in glazed areas. Are there infrequently
used or unsecured outbuildings which present opportunity and risk?).
Has consideration been given to installing blue ‘anti-injection’ lighting in bathrooms and toilets?
Are kitchen knives and other sharp utensils and any tool-kits kept in secured areas and systematically accounted for?
Is there sufficient discreet visibility into communal areas?
Is medication kept in accordance with Approved Premises practice guidance including good recording systems for issue
and checks made to ensure that medication has been issued to the resident in accordance with the prescription?
Does the Approved Premises team actively promote good physical and mental health?
Are there first aid/resuscitation packs at principal points around the premises/or routinely carried by all supervisory staff?
Is there good access to telephone and contact addresses for those organisations who could offer a potential service to
relevant residents and is it rapidly accessible for residents in crisis?
Is the Approved Premise located near a ‘suicide hot-spot’ and if so can action be taken to reduce access?
Are there processes in place to notify the Public Protection Unit at the National Probation Directorate of the death and
(subject to arrangements being implemented) the Office of the Ombudsman?

STAFF TRAINING AND AWARENESS

Is there an appointed Suicide Prevention Co-ordinator within each hostel team to ensure that the issues of sudden death
remain a priority and there is a central point for learning?
Is the matter included as part of new staff induction?
Is sudden death included in staff training plans or in individual staff members development plans?
Are there routes to ensure learning from all Approved Premises within the region is shared?
Are there ‘advisory’ links with other professionals (CPN/ SPCs in prisons, Samaritans etc, to give general advice to the
Approved Premises team or specific case advice?
Are all staff aware of those statistically most at risk or the statistically most ‘at-risk’ periods?

STRUCTURES AND SYSTEMS

Are there systems in place to ensure that those most at risk can be (discretely) identified by all staff?
Are potentially serious allergies assessed and recorded?
Are identifying features and next of kin details always satisfactorily recorded?
That is always clear in the risk management plan exactly what the risks are and what will be done to contain or reduce
them and what factors may increase the risk and what will be done to prevent escalation.
Are the specific actions identified in the risk management plan allocated to specific members of staff for them to carry
them out?
Are review structures in place?
Are there 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 and that when this has been done it is accurately recorded in the log?
Is there an Approved Premises strategic plan for the prevention of sudden death and is this compatible or shared across
all Approved Premises within the Area (and ideally within the region)
Are referring staff aware of the strategic plan?
As part of the Leadership task, do managers demonstrate that Sudden Death Prevention is an important element of any
well-managed, well-run Approved Premises?
Are there systems in place to record serious incidents of significant self-harm and other events where a fatality might
have occurred?
Do the above incidents receive a review to take the opportunity of recognising good practice and identifying areas for
improvement or change?
Are structures in place to ensure that the Public Protection 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?

PC02/2003 - Deaths of Approved Premises' Residents 12

WHAT TO DO IN THE EVENT OF AN INCIDENT OF SIGNIFICANT SELF-HARM OR A FATALITY

If there is an event on-site of serious self-harm:

• 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 given the limited skills of approved premises staff in first-aid and
resuscitation techniques.
• Do not leave resident unattended.
• Staff to 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 the securing the personal belongings of the deceased.
• Notify on-call manager, Assistant Chief Officer as soon as practicable.
• ACO to notify Chief Officer, Chair of Board, and Public Protection Unit at the National Probation Directorate and
also ensure Ombudsman’s Office has been notified (if implemented arrangement) and 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 hostel 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 member 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 any cosmetic 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.

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 • Prepare for the visit of the Ombudsman’s Office: 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 of the Coroner.

ADDITIONAL READING

Howard League for Penal Reform

‘Suicide and self harm prevention following release from custody’

HM Prison Service
Safer Custody Group Annual Reports

Health Promotion Strategy for Prisons

www.doh.uk/prisonhealth

National Probation Directorate

Approved Premises Handbook

Towl, Smith and McHugh

‘Suicide in Prisons’
Published by BPS Blackwell

Department of Health
‘National Suicide Prevention Strategy for England and Wales’
29158 2P 3k Mar 03 (CWP)
www.doh.gov.uk/mentalhealth

‘Making it happen: a guide to delivering mental health promotion’

www.nimhe.org.uk

PC02/2003 - Deaths of Approved Premises' Residents 14

ADDITIONAL ISSUES

• On average a person dies every two hours in England as a result of suicide

• Suicide is the most common cause of death in men under 35
• Suicide is the main cause of premature death in people with mental illness
• Rates of suicides in young men have risen but declined in other groups
• The main causes of death are hanging and self-poisoning with psychotropic or analgesic drugs
• The highest rates of suicide occur in social class V
• Government objectives include a reduction in the number of suicides of people who have recently been in contact
with mental health services, suicides by young men, and suicides following deliberate self-harm as well as a
reduction in the number of suicides by prisoners
• In Approved Premises the most ‘at risk’ group are bailees followed by licencees
• The most critical period is the weeks following admission

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