Prison mental health services unsafe, review says

Investigators interviewed 22 members of staff and two prisoners at the Jurby facility

Mental health services at the Isle of Man Prison were "inadequate and unsafe" at the time a prisoner was found dead, a review has concluded.

An inquest jury ruled there was a "missed opportunity" in the care of Craig Anderson, who was found unresponsive in his cell on 25 November 2022, the day after he was jailed for five years.

The Prisons and Probation Ombudsman (PPO) also found government support was needed to improve staffing levels, governance and the management of risk at the Jurby facility.

The Department of Home Affairs (DHA) previously confirmed changes had been made following the death, including the adoption of the UK's self-harm management policy.

The report, commissioned by the department and undertaken by the PPO, was made available to the jury during the inquest but has only now been published publicly.

As part of the independent review an investigator and clinical reviewer spoke to 22 members of staff and two prisoners in June 2023, with the governor and general manager for integrated mental health services interviewed the following month.

The investigation found staff at the facility had not been trained "how to effectively use suicide and self-harm prevention measures".

Mr Anderson had been placed on the prison's self-harm risk management policy, known as a folder five, on a number of occasions while in custody but was not under the assessment when he died.

The report said staff had closed the procedures "prematurely on 18 November and did not consider that his sentencing date had been postponed until 24 November".

They also "missed several opportunities to reopen" the folder five following his sentence and "placed too great an emphasis on his assurances that he did not have any thoughts of suicide or self-harm when assessing his risk".

The clinical reviewer found there was "confusion" about referrals to the prison's mental health provision, which itself was "inadequate and unsafe".

"The care Mr Anderson received was not equivalent to that which he could have expected to receive in the community," the reviewer said.

The report also found the prison had not made "sufficient changes or responded to the learning" from the death of another prisoner in March 2020.

Craig Anderson was found dead in his prison cell on 25 November

Making 15 recommendations, the PPO said the Department of Health and Social Care and Manx Care should review mental health services at prison and provide a dedicated mental health service, which was sufficiently resourced.

The island's health care body should also undertake a "health needs assessment" in order to "determine the prevalence of mental health conditions and need", it said.

During the inquest, prison governor Leroy Bonnick confirmed there was now a part-time mental health nurse working at the prison, a role which had not been in place at the time of Mr Anderson's death, and he was looking to double that support.

The review also found the DHA should consider "immediately commissioning an independent investigation in the event of any future non-natural deaths at the Isle of Man Prison", it added.

Manx Care and the Isle of Man government have been asked for a response to the report.