Self-Inflicted Deaths
• Time delays - referrals to MHT, initiating SPAR or accessing
prescribed medication
• Professional misconduct - assessments, care plans and reviews,
recording medical notes or concerns
• Poor communication - between prison officers at handover or
committal, and with prison healthcare
• Medicine management issues - decisions regarding supervised
swallow, in-person medication, drug testing, accessing notes
from GPs
• Disjointed care - incomplete assessments, failure to investigate
frequent committals and underlying issues, assumptions about
mental health, inter-prison transfers without clinical risk
assessments, hot / cold debriefings