HMP Doncaster

Section 1. Safety
Self-harm and suicide prevention
Expected outcomes:
The prison provides a safe and secure environment which reduces the risk of self-harm
and suicide. Prisoners are identified at an early stage and given the necessary support.
All staff are aware of and alert to vulnerability issues, are appropriately trained and have
access to proper equipment and support.
1.21 The incidence of self-harm was very high. There had been three self-inflicted deaths in the previous
18 months, but important recommendations following these deaths had not been implemented or
followed up. Some prisoners at risk of self-harm were isolated in poor conditions with insufficient
activities, staff did not always have time to care for them, and case management processes were
poor. There was a new Listener scheme, but prisoner access was currently limited. The segregation
unit constant watch cells were wholly inappropriate for people in crisis.
1.22 In our survey, 44% of prisoners said they had emotional well-being or mental health
problems. The incidence of self-harm was very high compared with similar prisons, with 329
incidents in the previous six months, involving 236 prisoners. There were 55 at-risk
prisoners subject to assessment, care in custody and teamwork (ACCT) case management
and one on constant watch during the inspection. There has been 534 ACCTs opened in the
previous six months.
1.23 There had been 11 deaths in custody since the last inspection, three of which were selfinflicted.
The prison had not effectively implemented some key recommendations made by
the Prisons and Probation Ombudsman (PPO) following its reports into these deaths, such as
implementing effective ACCT care planning (see main recommendation S40).
1.24 Around three-quarters of staff had current ACCT training, which was a big increase since
the last inspection, but training for the remainder was still required. ACCT documentation
was completed but not always sufficiently promptly, and information on triggers and the
quality of care maps were poor. Reviews were not always sufficiently multidisciplinary, and
mental health staff were not always present at case reviews where mental health was a
primary factor. Activity sessions aimed specifically at prisoners on ACCTs were a positive
initiative but not enough was done to encourage them to attend. Many prisoners at risk of
self-harm were isolated in poor conditions, and locked in their cells for long periods with
insufficient activities. They told us that staff were caring, but had little time to talk to them
(see main recommendation S40).
1.25 Buddies (see also paragraph 1.6) provided some good support to prisoners, and there was
now a new Listener scheme (prisoners trained by the Samaritans to provide confidential
emotional support to fellow prisoners). However, prisoner access to Listeners was
sometimes hindered, particularly at night, due to lack of staff to escort them to units (see
main recommendation S40). There were two care suites, which had been used on 66 nights
in the previous six months, and further care suites were being developed for Listener use.
1.26 From January to June 2015, 60 prisoners on ACCTs had been held in the segregation unit
(see paragraph 1.56). Two constant watch cells on the unit had been used 22 times for 11
prisoners in the previous six months. During the inspection, one was occupied by a prisoner
who had been on and off constant watch since May 2015, and who was awaiting a transfer to
a secure hospital. The cells were wholly inappropriate for people in crisis; they were stark
and grubby, and the plastic-covered doors inhibited communication with health care staff
undertaking the watch.
22 HMP Doncaster