Wales are not unique in this respectand epidemiological studies show that suicide rates in the prison population are greater than that of the general population . In European countries, the prison suicide rate is approximately 7 times higher than in the community. (World Health Organisation, 2014). Prison suicide rates in North America are also increasing. Government data shows that selfinflicted deaths increased 9% between 2012 and 2013 and account for over a third of deaths in correctional institutes (Noonan & Ginder, 2013). Although self-inflicted deaths in Australian prisons have decreased in recent years, they are still higher than those at liberty (Willis et al. 2016) as are suicides inCanadian institutes (Sapers, 2011).Self-harming, or self-injurious behaviours (SIB) also present a challenge for prisons. Case-control data demonstrate the self-harm rate in English and Welsh prisoners are 5-6% in males and 20-24% of females respectively (Hawton et al., 2014). These behaviours can occur for a number of reasons including; as an attempt to influence the environment, emotional regulation, or as a response to the symptoms of mental illness (Jeglic, Vanderhoff & Donovick, 2005). . They have however been identified as a risk factor for suicide in prison; albeit with a comparatively low absolute risk (Hawton et al, 2014). Whilst suicide risk is regarded as generally heightened during the early stages of custody (Crighton, 2006; Dahle, Lohner & Norbert, 2005) previous self-harm canbe predictive of suicidal ideation for new prisoners (Slade & Edelmann, 2014) In England and Wales, recent priorities outlined in agreements made between the National Offender Management Service (NOMS), Public Health England, and NHS England (2015) indicate a commitment to further improving the approach to managing prisoners at risk of both self-harm and suicide 1 In this paper the term 'prison estate' refers to all institutes used to incarcerate both remand and sentenced offenders.2 ), Given that early identification of suicidal prisoners is considered important to reduce deaths (Blaauw et al, 2001) the use of risk screening tools seems an obvious consideration. However, to date, this approach has proved controversial and met with, at best, limited success (Perry & Olason, 2009 to the attention of mental health professionals after an overt gesture has been made to self-injure (Blasko, Jeglic & Malkin, 2008). Suicide screening tools may be inappropriate for use in settings other than those which they were designed for but have nonetheless been implemented prior to any additional validation (Boudreaux & Horowitz, 2014;Perry et al, 2010). Likewise, In England and Wales a healthcare reception screening tool for use in primary care in both male and female prisons was developed, yet figures for 3 sensitivity and specificity rates pertaining to suicide risk were unavailable (Grubin, Carson & Parsons, 2002). An evaluation study found many institutions to be using an untested but modified version of the tool (Shaw et al, 2008 Suicide Te...

Background. Self-harm is common in prisoners. There is an association between self-harm in prisoners and subsequent suicide, both within prison and on release. The aim of this study is to develop and evaluate a prediction model to identify male prisoners at high risk of self-harm. Methods. We developed an 11-item screening model, based on risk factors identified from the literature. This screen was administered to 542 prisoners within 7 days of arrival in two male prisons in England. Participants were followed up for 6 months to identify those who subsequently self-harmed in prison. Analysis was conducted using Cox proportional hazard regression. Discrimination and calibration were determined for the model. The model was subsequently optimized using multivariable analysis, weighting variables, and dropping poorly performing items. Results. Seventeen (3.1%) of the participants self-harmed during follow up (median 53 days). The strongest risk factors were previous self-harm in prison (adjusted hazard ratio [aHR] = 9.3 [95% CI: 3.3–16.6]) and current suicidal ideation (aHR = 7.6 [2.1–27.4]). As a continuous score, a one-point increase in the suicide screen was significantly associated with self-harm (HR = 1.4, 1.1–1.7). At the prespecified cut off score of 5, the screening model was associated with an area under the curve (AUC) of 0.66 (0.53–0.79), with poor calibration. The optimized model saw two items dropped from the original screening tool, weighting of risk factors based on a multivariable model, and an AUC of 0.84 (0.76–0.92). Conclusions. Further work is necessary to clarify the association between risk factors and self-harm in prison. Despite good face validity, current screening tools for self-harm need validation in new prison samples.

The current prison population in England and Wales has multiple, complex healthcare needs, presenting unique challenges to those caring for prisoners. Prison numbers have increased dramatically in the last 10 years. There are now approximately 84,000 prisoners in England and Wales and 120,000 new episodes of imprisonment each year . The authors all contribute to prison healthcare. Below, we discuss a key issue arising from first-hand experience of prisoners' health and social care needs, the prescription of psycho-active drugs by primary and secondary care practitioners. This is a core medical task, but beset with difficulties. These difficulties are not necessarily encountered in other areas of prison healthcare. However, they do illustrate how providing healthcare to prisoners is complex, often lacking a research base and can have pitfalls that are not obvious to the outsider.

No abstract

No abstract

No abstract