Prison oversight

This chapter explores what post-suicide investigations achieve. Using the three elements of oversight mechanisms to guide analysis (directors, detectors and effectors), it demonstrates that prisons have no shortage of directors and detectors, but very limited effectors, both in relation to prison suicide and in general. It is difficult to establish the merit of post-death investigations because their failures are highlighted but their successes are not. The chapter demonstrates the value of post-suicide investigations, referencing the investigations which followed the deaths of Dean Saunders and Sarah Reed. The legimitising effects of prisons oversight mean that overseers have a responsibility to speak truth to politicians which (arguably) outweighs any constraints in their remits. Prison overseers in England and Wales are more than legitimising functions that shore up state activity, but that they could achieve significantly more by targeting the government succinctly, repeatedly and robustly. It is also for the rest of us to take up the argument that the situations in which Dean Saunders and Sarah Reed died were not aberrations, but foreseeable outcomes of marooning very sick people in prison. It is to be expected that internal prison administration will fail. This book provides example after example.

Post-suicide investigations

This chapter illustrates the series of post-suicide investigators, including the police, ombudsman and coroner. It examines the 2013-2016 suicide cluster at HMP Woodhill to illustrate these investigations, their value and their limitations. It concludes that the post-suicide investigations are broadly Article 2 compliant and offer no shortage of vigorous critique, but also explains that Article 2 does not require that lessons be learnt and does not direct accountability to those with the capacity to implement said lessons. This is a greater limitation in England and Wales than the more commonly recognised issues with family participation and independence. The discourse of lesson learning is shown to be unhelpful in many cases of prison suicide, manufacturing mystery where there is none. It is not a mystery when prisoners die with untreated mental health problems because the prison’s mental health team is severely understaffed and has been for years, as identified multiple times by multiple prison overseers. The discourse of lesson learning also obfuscates the role of deliberate political decisions in reducing staffing levels and increasing the prison population such that staff are set up to fail and cannot follow Prison Service Orders and Instructions.

Prison suicide and its aftermath

This chapter describes the global importance of analysing post-prison suicide investigations and introduces the case study of England and Wales, which has a substantive prison monitoring and post-death investigations framework yet recent record numbers of prison suicides. This case study is used to provide the first analysis of these investigations in this book. This chapter details the importance of acknowledging that ‘manipulative’ prisoner behaviour can be lethal and recommends foregrounding potential death rather than querying prisoners’ potentially unknowable intentions. It outlines the underappreciated roles of suicidogenic discourses, institutional apathy and prisoner stigmatisation in suicide prevention, and explains the particular difficulties of suicide prevention work. It outlines that suicide prevention was significantly more effective from 2005-2011, which was predictably overturned by swingeing staff cuts from 2012.

Experiencing investigations

This chapter explores prison staff and prisoners’ families’ experiences of the full complement of post-prison suicide investigations. It highlights the burden that these investigations can impose on bereaved families and prison staff. It raises concerns about the degree of scrutiny to which prison staff can be subjected given their limited agency. It notes the unclear relationship between the findings of post-suicide investigations and suicide prevention. It restates the need for accountability of political decision makers. A publicly resourced independent support service for bereaved families is suggested.