B.14.ACRP.02 At Risk / Self-Harm / Suicide Management

Procedure Standard

The prevention, where possible, of incidents of suicide or self harm.

• All prisoners are to be immediately screened and assessed for risk of self-harm or suicide upon arrival at the prison. All prisoners so identified are to be provided with an appropriate Risk Treatment Plan which will address placement, counselling, medical care, psychological/psychiatric evaluation and treatment, security frequency of observation, conditions of watch and documentation requirements, visitation arrangements, and such other matters as are deemed necessary.
• All prisoners who are charged with Murder or Manslaughter shall be deemed to be At Risk of Self Harm or Suicide and managed in accordance with this procedure.
• All prisoners who are under the age of 17 years shall be deemed to be At Risk of Self Harm or Suicide and managed in accordance with this procedure.
• All non English-speaking prisoners shall be deemed at risk until an interpreter is available to translate assessment documents and report accordingly. The HRAT team will then review at risk status
• The Risk Treatment Plan shall be developed by a team of persons from the Programmes, Health Service and Operations areas and other specialists as deemed necessary, and shall be based upon an integrated shared approach to all pertinent information regarding the subject prisoner's circumstances, condition and treatment progress.
• This procedure recognises the importance of training all staff to be acutely aware of prisoner at-risk indicators and to actively contribute to the decisions regarding the assessment and treatment of prisoners exhibiting such at-risk indicators. All staff are to err on the side of caution when dealing with potentially suicidal prisoners.

Necessary Forms and Requirements

Procedure

1. On reception all prisoners will be assessed by the Assessors and the nurse, to identify immediate needs and risk status. On completion of this assessment the nurse will carry out a Health Reception Screen to determine any immediate health needs.
2. Prisoners who are identified as being currently At Risk of Self Harm or Suicide through the assessment process shall be referred immediately to the nurse.
3. The nurse shall, as soon as practicable, interview the prisoner using the Reception At Risk Screen, and enter findings on the New Arrival Risk Assessment form and in the medical record. If the nurse disagrees with the Assessor’s findings then they shall meet and discuss the case. If either person believes the prisoner is At Risk of Self Harm or Suicide then the nurse, in conjunction with the Assessor and the Unit Manager will formulate an Interim Risk Plan (IRP) and place the prisoner in the Special Needs Unit.
4. The Nurse Team Leader is to be informed immediately if there are any difficulties with prisoner placement and of any prisoner assessed as Category A.
5. The IRP shall address as a minimum:

• Placement of the prisoner in a particular cell
• Level and condition of observation to be provided, A or B.
• Other measures as deemed necessary

6. If the prisoner is assessed as category A, he will be placed in a Safe Cell. The medical officer and Prison Manager are to be informed, so that the prisoner can be assessed within 12 hours of being placed in the safe cell.
7. If the prisoner is escorted to the health centre: while the prisoner is present in the health centre and awaiting assessment, the Corrections Officer shall:

• Observe the prisoner not less than every two minutes; and
• Document such observations on the health services centre log.
• Ensure any prisoner who is viewed as being at risk is not left alone.

8. All prisoners identified as having a history of being at risk of Self Harm or Suicide within the last 5 years, but are not considered to be currently at risk, shall be urgently referred to the Psychologist on the appropriate form, for further assessment. This assessment must be conducted within 24 hours of reception.
9. Where any doubt exists, consider the prisoner to be at risk of self-harm or suicide and manage according to Category A procedure.
10. On arrival in the Special Needs Unit the prisoner will be managed according to the Interim Risk Plan, an At Risk File will be initiated and stored in the Special Needs Unit housing control room.
11. The Psychiatric Nurse and Psychologist will, as soon as is practicable, reassess the prisoner and formulate a Risk Treatment Plan.
12. The Risk Treatment Plan will be forwarded to the Unit Manager, who will sign the plan, ensure that unit officers are aware of content, place the RTP on the prisoner’s At Risk File, and ensure that receiving staff stamp the prisoner file (in red) accordingly.

Prior Medical History

1. Any information received by health staff prior to a prisoner’s reception that will have a bearing on that prisoner’s risk status, must be immediately communicated to the appropriate Assessor.
2. It is the responsibility of nursing staff on duty at the time of receipt of a prisoner identified as At Risk, to access any previous medical record and combine it with the current record. If a previous record is available it is to be reviewed for:

• Evidence of deliberate self harm;
• Evidence of suicidal behaviour;
• Evidence of other significant medical or psychiatric illness;
• Previous or historical alerts and pre-sentence reports

3. The nurse shall document the review of the prisoner’s former medical record on the Clinical Record Sheet.
4. If the previous medical record is not available, documentation that it was not available shall be placed on the Clinical Record Sheet. The previous medical record should be retrieved as a matter of urgency and a file review completed by the nurse as soon as the file has been received.

Identification, other than through New Arrival Assessment

1. It is the responsibility of every staff member becoming aware of any prisoner exhibiting at risk of self harm or suicide behaviour, or the existence of high risk indicators to:

• Immediately notify the relevant Unit Manager/PCO, and complete a Local Reassessment Form.
• Inform the relevant Unit Manager/PCO that you are moving the prisoner, accompanied by the Local Reassessment Form, to the health centre for observation and further assessment by the nurse.

2. Following the assessment, the nurse and the Unit Manager shall formulate an Interim Risk Plan, and place the prisoner, accompanied by the IRP and LRF, in the Special Needs Unit.

At Risk File

1. When the prisoner is received into the Special Needs Unit the Corrections Officer will compile an At Risk File, which will be kept in the Special Needs Unit Housing Control.
2. The At Risk File will be maintained in a distinctive red folder, stamped AT RISK FILE.
3. The following documents will be stored on the prisoner’s At Risk File:

• B.14.01.F1 New Arrival Risk Assessment
• B.14.03.F1 Local Reassessment
• B.14.ACRP.F1 Reception At Risk Screen
• B.14.ACRP.F3 Interim Risk Plan (IRP)
• B.14.ACRP.F4 RTP/IRP Modifications
• B.14.ACRP.F5 Observations
• B.14.ACRP.F6 Corrections Officer’s Prisoner Record
• B.14.ACRP.F10 Risk Treatment Plan (RTP)
• B.14.ACRP.F12 Release from Watch
• B.14.ACRP.F13 Risk Information
• Incident Reports
• Other Specialist Reports

4. The psychiatric nurse and the psychologist members of the HRAT will, in addition to recording in their own service records, document all meetings with the prisoner in the prisoner’s At-Risk File.
5. Once the At Risk File has been closed, all medical and psychiatric reports are to be placed in the prisoner’s health file
6. All other documentation is to be placed in the prisoner’s institution file (Division C).

High Risk Assessment Team (HRAT)

1. The HRAT will be comprised of the following, plus other specialists as necessary:

• Programmes – Assessment Manager/ delegate
• Psychologist and Psychiatric Nurse
• Operations – Unit Manager, SNU /PCO SNU.

2. Any prisoner identified, as At Risk will be reviewed by HRAT on day 2 after their identification. Ongoing reviews will occur as per the Risk Treatment Plan.
3. Any prisoner referred to Psychiatric Services will normally be reviewed by HRAT with the presence of a Psychiatric Services representative.
4. Minutes shall be taken at each HRAT meeting and distributed to the Psychologist, Assessment Manager, Prison Manager, appropriate Custodial Managers, Regional Health Manager, Nurse Team Leader and Psychiatric Services when appropriate.
5. At each HRAT meeting the Unit Manager, SNU shall ensure that the At Risk File is available. The Nurse Team Leader shall ensure that the medical record is available. The Psychologist shall ensure that each prisoner’s psychological records are available.

Risk Treatment Plan (RTP)

1. The psychiatric nurse and psychologist members of the HRAT shall individually interview the prisoner identified as at risk of self-harm or suicide and shall, after such interviews, meet and establish a RTP.
2. The RTP shall address as a minimum:

• Level of Risk of Self-Harm or Suicide: A (High, requires round room), B (Medium) and C (Low);
• Placement of the prisoner in a particular cell or accommodation;
• Conditions and frequency of observation to be provided;
• Need for follow up medical/psychological care;
• Allocate a peer support prisoner if appropriate;
• Date of next review; and
• Other measures as deemed necessary.

3. The RTP shall remain in the prisoner’s At-Risk File in the Special Needs Unit Housing Control Officer's station.
4. The Unit Manager signing the RTP shall:

• Ensure that the Special Needs Unit Housing Control Room Officer or other officer assigned responsibility for such, understands the content of the RTP.
• Obtain the officer's signature upon the RTP evidencing such understanding.

5. The Special Needs Unit Manager/PCO will review and sign, at the commencement of each a.m. shift the At Risk Observation Forms.
6. The Psychologist, Unit Manager and Nurse Team Leader shall, to ensure continuity of care, review all documentation related to RTPs quarterly.

Risk Treatment Plan Modifications

1. The HRAT Review Committee will meet at least twice weekly to review IRPs and RTPs of category A, B and C at Risk of Self Harm or Suicide prisoners and other prisoners as required. The HRAT will assess the prisoner to determine when the treatment plan or risk level should be modified. All prisoners on category A risk watch will continue to be monitored through risk levels B and C.
2. RTP modifications are documented on the RTP modifications form and placed in the prisoners At-Risk File. The reasons for modification are documented on the Modifications Form.
3. The Unit Manager/PCO, SNU signing the modification sheet shall place a copy of that sheet in the prisoners At Risk File and shall advise the unit control officer of any variations to the plan, obtaining the unit officer’s signature as evidence of that officer’s understanding of any changes made.
4. Modifications may only be made between category A and category B on Interim Risk Plans.
5. The above modification may only be made following review by the nurse, the relevant correctional manager, and following consultation, by phone, with the Psychologist and the Medical Officer. Any such modification, and the reasons supporting the modification, must be documented on the medical record and on the RTP Modifications form with the original being placed in the prisoner’s At Risk File.

Referral To Psychiatrist

1. Prisoners who may require psychiatric intervention are to be referred to the Psychiatrist by the Medical Officer or, in his/her absence, a Registered Nurse.
2. Every prisoner identified with a clinical psychiatric diagnosis is to be referred to Auckland Regional Forensic Psychiatric Services, as per the Service Level Agreement (ACRP/Waitemata Health), at the first available opportunity. A Psychiatrist will evaluate the prisoner and provide treatment as required.
3. A log will be maintained by the Nurse Team Leader of all psychiatric referrals made for prisoners at risk of self-harm or suicide.

Release From At Risk Watch Status

1. Prisoners shall not be released from RTP At Risk of Self Harm or Suicide watch status until:

• They have been reviewed by the HRAT;
• The HRAT documents, on the Release Form, that in their unanimous opinion the prisoner is not currently At Risk of Self Harm or Suicide; and
• If any staff member does not concur, the prisoner will remain on At Risk of Self Harm or Suicide Watch.

2. Irrespective of the decision of the HRAT to withdraw At Risk of Self Harm or Suicide Watch status, each staff member is to be aware of their duty of care and that situations can change rapidly and that they are to notify the relevant Unit Manager of any and all concerns that they may have regarding an prisoner’s well being.
3. An prisoner may not be released from At Risk of Self Harm or Suicide Watch status resulting from an Interim Risk Plan until authorised by the HRAT during normal business hours.
4. An prisoner may not be released from At Risk of Self Harm or Suicide Watch status if he is categorised as level A or B.
5. Prisoners who have been taken off At Risk of Self Harm or Suicide Watch shall have a follow-up plan determined by the HRAT. The plan will include as a minimum, that the prisoner will be on 1 hourly recorded observations for at least a week, and any further referrals or follow up appointments.

Responsibility During Absence

1. Any responsibility, which is herein assigned to any individual, includes the obligation to ensure that such responsibility is delegated to an appropriate person in such individual's absence.

At Risk of Self Harm or Suicide Indicators

1. Research in New Zealand shows that the high risk categories of prisoners attempting self harm or suicide are:

• On remand;
• Maori;
• Youth.

2. Any staff member observing any of the following risk indicators and/or unusual behaviour should notify the relevant manager and refer the prisoner for assessment by health staff. This list is a guide only – it is not exhaustive.

• Previous history of suicide attempts;
• Recent excessive drinking and/or use of drugs;
• Intoxication withdrawal;
• Recent loss of stabilising resources;
• Severe guilt or shame over an offence;
• Rape or threat of rape;
• Stress factors - loss of loved one, divorce, financial loss;
• Recent loss of job;
• Rejection by peers/family members/significant others;
• Current mental illness;
• Poor health or terminal illness;
• Approaching an emotional breaking point;
• Giving away personal property;
• First 24 hours of confinement;
• Waiting for trial;
• Sentencing;
• Previous Psychiatric History;
• Unfavourable reports;
• Impending release;
• Holiday periods;
• Anniversary;
• Darkness/night time;
• Period of decreased staff supervision (night time, weekends, shift change);
• Unfavourable news of any kind.

Signs To Observe

1. Any staff member observing any of these signs should notify the relevant Unit Manager and refer the prisoner for assessment by health staff. This list is a guide. There may be other risk indicators that should also be reported.

• Intoxication, slurred speech, lack of balance;
• Unsteady on feet or cannot walk;
• Depression or paranoia;
• Strong guilt or shame;
• Severe agitation or aggressiveness;
• Projects hopelessness or helplessness;
• No sense of future;
• Extreme anxiety, restlessness;
• Withdrawal, isolation;
• Noticeable behaviour changes;
• Speaks unrealistically about getting out of prison;
• Increasing difficulty relating to others;
• Does not effectively deal with present, pre-occupied with past;
• Attention getting gestures;
• Deliberate self harm;
• Loss of interest in activities or relationships;
• Change in eating and sleeping patterns;
• Talks openly about suicidal ideas;
• Noticeable personality changes.

2. Guidelines for use by High Risk Assessment Team

Flowchart

Key Roles and Responsibilities

Assessor

1. Ensure that all prisoners are assessed on reception for risk status using the Initial Risk Assessment form and the New Arrival Risk Assessment form (NARA).
2. If a prisoner is identified as being at risk, refer that prisoner to the nurse with a copy of the New Arrival Risk Assessment form, documenting the reasons for referral.
3. If the nurse disagrees with the Assessors findings, they shall meet and discuss same. If either party believes the prisoner to be at risk, the prisoner will be managed as such.
4. Attend HRAT meetings as required.

Corrections Officers

5. Upon becoming aware of a prisoner exhibiting at risk of self-harm or suicide behaviours or the existence of high-risk indicators, notify the relevant Unit Manager and complete a Local Reassessment Form (LRF).
6. At the direction of the Unit Manager, escort the prisoner to the health centre for assessment by the nurse.
7. Hand the prisoner over to the health centre corrections officer if one is present. If not remain with the prisoner until all assessments are complete and the prisoner’s placement is decided upon.
8. Arrange for CSU movements CO, or, If necessary escort the prisoner accompanied by the IRP and LRF to the Special Needs Unit, and hand the prisoner over to the Special Needs Unit Officer
9. Any prisoner viewed as being at risk is not to be left alone.

Health Centre Corrections Officer

10. Any at risk prisoners that arrive at the health centre, for assessment view possible placement in the SNU, shall be observed at least every two minutes, and these observations shall be recorded in the health centre log.
11. Arrange for CSU movements CO, or, If necessary escort the prisoner to the Special Needs Unit accompanied by all necessary documentation, and hand the prisoner over to the Special Needs Unit Officer
12. Any prisoner viewed as being at risk is not to be left alone.

Nurse

13. All receptions will be assessed for ‘at risk’ status using the Reception At Risk screen (RARS). Any prisoner viewed as at risk, by either the NARA or the LRF, will be assessed for at risk status.
14. The assessment and its findings will be documented in the medical record as well as on the NARA or the RARS.
15. Any prisoner viewed as at risk by the LRF will be assessed for at risk status using the Suicide Assessment form.
16. If the nurse’s findings differ from that of the assessor or the corrections officer, they shall meet and discuss the findings. If any party believes the prisoner to be at risk, the prisoner will be managed as such until the HRAT assesses otherwise.
17. Any prisoner assessed as being at risk will have an Interim Risk Plan developed by the nurse. The IRP will contain, the prisoner’s placement, observation level (A or B) and any other measures deemed necessary.
18. Ensure the IRP is signed off by the Unit Manager or the senior custodial officer (PCO) on duty.
19. The prisoner will be escorted to the SNU with the IRP. If there are any difficulties with prisoner placement the nurse is to immediately inform the Nurse Team Leader.
20. The nurse will immediately inform the Nurse Team Leader and the medical officer of any prisoners assessed as Category A.

Unit Manager

21. Ensure that any prisoner identified as at risk via the LRF is escorted to the health centre for assessment and is not left alone.
22. Sign the IRP of any prisoner assessed as being at risk and ensure the Special Needs Unit Officer is aware of its contents and signs as such.
23. Attend HRAT meetings and ensure that the At Risk file is available to the meetings.
24. Sign all Risk Treatment Plan’s and Risk Treatment Plan Modifications, and ensure that the Special Needs Unit Officer understands the terms and conditions of such. Obtain the SNU officers signature evidencing such understanding.
25. Review and sign at the commencement of each a.m. shift the At Risk Observation forms.

Special Needs Unit Housing Control Officer

26. Ensure that any prisoner arriving in the Special Needs Unit is managed as per the Interim Risk Plan.
27. Initial the IRP upon arrival of the prisoner and allocate accommodation.
28. Initiate and maintain an At Risk file for all receptions into the SNU, which will be stored in the SNU Housing Control.
29. Sign all Risk Treatment Plans and Risk Treatment Plan Modifications.
30. Ensure all prisoners are managed as per the RTP requirements.
31. On an on-going timely basis, document on the At Risk Observation Form compliance with the observation requirements established by the RTP.
32. Complete on a daily basis the Corrections Officers Prisoner Record for all prisoners in the SNU.
33. Complete the Risk Information Form for any prisoners who are to be received by other agencies, and forward the form to the Receiving Office.

Psychiatric Nurse

34. All prisoners on an IRP will be referred to the psychologist. Then assessed by the psychiatric nurse, who in conjunction with the psychologist will formulate an RTP.
35. Coordinate all HRAT meetings and ensure that all requirements of IRPs and RTP Modifications are carried out.
36. Sign all RTPs and RTP Modification forms.
37. Ensure that HRAT meeting minutes are distributed as required.

Psychologist

38. Interview all prisoners on an IRP as referred, then, in conjunction with the psychiatric nurse, formulate an RTP.
39. Attend all HRAT meetings and sign all RTP and RTP Modification forms as required.
40. Ensure the availability of the prisoner’s psychological record for all HRAT meetings.
41. In conjunction with the Nurse Team Leader and the Assessment Manager, carry out a quarterly review of all documentation related to RTPs.

Assessment Manager

42. In conjunction with the Psychologist and the Nurse Team Leader, carry out a quarterly review of all documentation related to RTPs.
43. Attend HRAT meetings and ensure that the Assessor’s file is available to the meetings.

Nurse Team Leader

44. Ensure the availability of the prisoner’s medical record for all HRAT meetings.
45. Maintain a log of all psychiatric referrals for prisoners at risk of self-harm or suicide.
46. In conjunction with the Psychologist and the Assessment Manager, carry out a quarterly review of all documentation related to RTPs.