Poor access to health care, confusion over responsibility for post-detention care and inadequate risk assessments may have contributed to more than a hundred deaths following police custody and prison detention.

New research shows that this lack of support is putting vulnerable people in jeopardy of losing their lives within a month after leaving police custody and prison detention, the Equality and Human Rights Commission has warned today.

Following on from our preventing deaths in detention inquiry, today’s new in-depth analysis of existing data and working practices across police and prison agencies, reveals a very worrying picture of serious gaps in care after people are released from police custody or prison.

Our report found:

• a lack of accountability and inadequate record-keeping by responsible agencies
• the wellbeing of people released from prison or police custody is not always monitored and managed properly after detention, even when it is known that they have a mental health condition which could put them at risk of suicide
• the information collated centrally on the deaths of people after detention in prison is of variable quality making it much harder to identify the true scale of the problem and tackle it
• risk assessments made by prison staff were routinely not shared with staff responsible for post release care

In 2015-16, there were 60 apparent suicides within two days following police custody, 18 of which occurred on the day of release, 24 one day after release and 16 two days after release. This is possibly linked to high levels of shame and problems in coming back into the community – an indication that post-release support is failing. The reality is that the number of suicides is likely to be higher than 60 due to the fact that police are often not aware of a death, meaning the link between the death and police custody will not be made.

The findings also reveal that from 2010-2015 there were 66 non-natural deaths following release from prison, most of which were from a drug overdose and within ten days of release. Drug use is a significant factor in post-prison deaths. Research has found that drug using ex-prisoners are up to eight times more likely to die in the first two weeks of release when compared to non-drug using ex-prisoners. We therefore welcome the Justice Secretary’s prison reform announcement last week which includes a proposal to test all offenders for drug use on entry and exit from prisons. This should be used to ensure those who are leaving prison are given the right support to address any substance issues.  In addition to this, good communication between the prison and community treatment programmes is essential in preventing such deaths. However, it is clear from today’s report that this needs to be improved.

Mental health is another significant factor in both post-police custody and prison deaths. Of the 60 people who took their own lives following police custody, 33 had known mental health conditions including depression, schizophrenia, or previous suicide attempts.

Chair of the Equality and Human Rights Commission, David Isaac said:

“When the state detains people, it also has a very high level of responsibility to ensure they are safely rehabilitated back into their communities, particularly those who may be vulnerable.

“Our report reveals a fractured state of post-detention care that is potentially leading to hundreds of deaths.

“The government and justice agencies must take seriously their duty of care to detainees and address some of the very basic mistakes we have identified, to provide proper support to people who have done their time.”

When someone is released from prison, relevant risk assessments should be shared with the probation teams who are responsible for managing any risk of self-harm. In addition, healthcare providers in prisons have a responsibility to ensure that local health teams are aware of any health issues that the prisoner faces. Our evidence highlights failures in following these procedures with poor communication between staff and relevant agencies which blocks crucial information such as risk assessments of former prisoners. Moreover, where good communication exists, providers’ ability to deliver effective services were hampered by budget cuts.

Concerns were raised when some of these issues were identified as the Commission gathered evidence for its previous inquiry into preventing deaths of adult in detention. The new research mirrors the findings of the previous inquiry very closely. It was clear that additional research was urgently needed to highlight post-detention deaths as a serious issue and the Commission has made recommendations to address failures. These include:

• All apparent suicides within 2 days of release from police custody should be referred by the police to the IPCC, to assess whether to carry out an Article 2 compliant investigation.
   
• All non-natural deaths within 2 weeks of release from prison should be referred to the Prison and Probation Ombudsman to assess whether to carry out an Article 2 compliant investigation.
   
• The Home Office should give further consideration as to whether responsibility for health and mental health care in police stations should be given to the NHS. As a minimum requirement, custody health care staff should have prompt access to NHS records in order to provide the best care and support.
   
• An inter-agency summit is convened to explore how these hidden deaths can be better exposed, and how the data can be made more reliable and comprehensible. Following the obligations set out in the Equality Act 2010, data collection and analysis should, in future, include reference to protected characteristics such as gender, where this does not compromise anonymity for those concerned, in order to monitor progress and identify any problems.
   
• More training is provided to support police custody staff in the identification and treatment of suspects who may be traumatised by the fact of arrest and investigation, and of others with mental health issues.
   
• More training is provided for all probation and Community Rehabilitation Company (CRC) staff (including those who work in approved premises) particularly in relation to inter-agency co-operation when working with those at risk of abusing illegal and prescription drugs.
   
• Criminal justice agencies review how far relevant policy documentation is immediately accessible and comprehensible for staff. This includes providing a ‘checklist’ of actions for dealing with people at crucially vulnerable moments in their lives.
   
• There should be an obligation on the appropriate authorities to carry out effective risk assessments before release from prison and police custody and information disseminated to all relevant agencies to enable them to provide appropriate safeguards and support. These obligations should be monitored within a framework of accountability.