At the same time, members of the panel were invited to take part in a major review, over a period of a year, into deaths in prison custody of young people between the ages of 18-24. This is a particularly vulnerable age group and pressure had been growing on the government to carry out a proper review into the root causes of deaths – almost all self-inflicted – and how to stop them. Participating in the review required a significant commitment of time, several days a month, but the opportunity to be involved in such an important piece of work, with the prospect of making a real difference was irresistible.

The panel, chaired by Lord Toby Harris and made up of academics, doctors from various disciplines, campaigners, me as the only full time practicing lawyer, and assisted by a small, but committed, secretariat, embarked on an intense period of investigation.

Terms of reference

Our terms of reference asked us to investigate self-inflicted deaths of 18-24 year olds since 1 April 2007, this being the date when the present scheme for preventing such deaths, the Assessment, Care and Custody & Teamwork care planning system (ACCT), was implemented. Our ambit thus covered 83 deaths and we also considered the four deaths of those under 18 during the same period. Some further 14 deaths have occurred since the review was commissioned. We were to look at issues such as vulnerability, sharing of information safety, staff/prisoner relations, staff training and family contact and to say whether lessons were being learned from deaths in custody and if not, what action should be taken to prevent further deaths.

It quickly became clear to the panel that we would have to look more widely than whether conditions and systems in prison could be changed to prevent suicides taking place, although that would be important. What was clearly called for was a root and branch inquiry into what was the purpose of prison for these young people, should they have been there in the first place, and could they have been diverted from the criminal justice system, either entirely, or at an early stage of their dealings with the police and the courts? The fewer vulnerable young people in harsh prison conditions, the fewer self-inflicted deaths would be likely to occur.

Evidence gathering

The panel embarked on an evidence gathering mission throughout 2014. A total of 26 hearings were held to take evidence from experts, professionals, and campaigning groups; written submissions were sought and 54 received. We commissioned academic literature reviews and number-crunching exercises. The panel members visited a whole range of prisons and other institutions where young people are held. And we listened to the harrowing stories from families and young people affected most by deaths in custody. Our 300-page report was published in July 2015. Our findings and recommendations were far-reaching.

From our visits to prisons, and from talking to and hearing from all sides involved in the system, we found ourselves questioning the current purpose of prison. It seemed to us that young people were incarcerated in grim conditions, often with little to do all day, and watched over by increasingly overstretched prison staff. No wonder young people become hopeless and more vulnerable in these conditions.

Panel recommendations

We recommended that much more needs to be done to make prison a supportive and worthwhile experience for young people to rehabilitate them back into the community. In line with the European Convention on the Prevention of Torture, we said that young adults should be able to spend at least eight hours a day out of their cell engaged in purposeful activity. [The reversal of the policy on books for prisoners is a small but welcome step.]

We also recommended that there should be holistic needs assessments and individual care plans for all young prisoners with appropriately qualified staff members – custody and rehabilitation officers (CAROs) – responsible for ensuring that the plan is delivered. With the help of a team of psychiatrists, we identified that almost half of those whose deaths we studied were suffering from a mental health disorder. However, the review of the case histories of our cohort revealed that in many cases staff did not demonstrate appropriate awareness of their mental health problems, underlining the need for robust initial mental health assessments of young people in prison. The lack of communication and proper sharing of information between various arms of the criminal justice and health systems was a recurring and troubling theme.

The review also looked closely at why young people were in prison in the first place. We called for an emphasis on prison as a last resort, with effective diversion schemes wherever possible, and judges and lawyers fully aware of what is available when a young person enters the criminal justice system. We heard from several schemes around the country, which successfully divert young people away from the courts and into appropriate mental health and social services schemes. The evidence is that these schemes are more cost-effective than prison, with the added benefits of lowering prisoner numbers. Better planning in early years to identify vulnerable children can prevent even initial contact with the criminal justice system and we recommended that a programme be developed to focus on this area.

Overall, our review of previous reports and reviews found that lessons had not been learned, and the same mistakes repeated themselves time and again in the cases we studied. Prison standing orders (PSOs) are well drafted to prevent self-inflicted deaths but we found, from the evidence we heard and our own observations in prisons, a “disconnect between what those in charge think should be happening and what is actually happening” on the ground. This has to be changed.

Lesson for lawyers

So why is this important to lawyers and judges? The report shines a light into the operation of the system, revealing fundamental flaws at all levels making prison a highly inappropriate and risky environment for vulnerable young people. Reading the report, judges will have greater awareness of what a young person will face when sentenced or remanded in custody, and may think twice before concluding that the right level of care and rehabilitation might be available there for those at risk. Both practitioners and the judiciary should ensure they are fully cognisant of local diversion schemes. Ultimately, to ensure that the right solution is found for vulnerable young people who find themselves facing criminal justice sanctions, proper communication and the sharing of information between agencies, practitioners and judges is essential.

As Lord Harris says in his foreword to our report, the review was a “once in a generation opportunity” to have an impact on the lives of some of the most vulnerable people in society. I hope we have taken that opportunity as fully as possible.

For more information on the IAP, see

Contributor Stephen Cragg QC

Comment by Frances Crook, the chief executive of the Howard League for Penal Reform:

The review by Lord Harris of Haringey into the self-inflicted deaths of young adults aged 18-24 in custody is a magisterial overview of the failings in the system. It is the most comprehensive analysis of why so many young people are dying in our prisons ever undertaken.

The final report notes that 101 people in this age group have died in prisons between 2007 and 2014. So far, in 2015, the Howard League is aware of another nine young people who have taken their own lives behind bars.

There are challenging findings for the new government to consider. Lord Harris rightly asks fundamental questions, such as why so many of these young adults were in custody in the first place. Prison should be used as a last resort. It remains a hugely expensive way to guarantee failure, yet cuts to budgets and staffing mean that whatever hope that prisons might be places of rehabilitation is faint indeed. The review describes an environment where young adults spend too much of their time locked in their cells “not sufficiently engaged in purposeful activities”, with their time “not spent in a constructive and valuable way”.

These findings have now been echoed by the outgoing Chief Inspector of Prisons, Nick Hardwick, in his final annual review. Broadening his view to prisoners of all ages, Hardwick writes: “You were more likely to die in prison than five years ago. More prisoners were murdered, killed themselves, self-harmed and were victims of serious assaults than five years ago. There were more serious assaults and the number of assaults and serious assaults against staff also rose.”

These are serious concerns and both the Harris review and the Inspector’s annual report have now landed on the desk of the new Justice Secretary, Michael Gove. It is to be hoped that he will absorb the lessons contained within and act to stop the scandal of people dying in prison.