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This resource contains information about suicide which may be upsetting to some people.


A question of restraint: Care and management for prisoners considered to be at risk of suicide and self-harm

Prisoners Prisons Prison administration Mental health Suicide New Zealand
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In 2007, the Ombudsmen were designated as one of the National Preventive Mechanisms (NPMs) under the Crimes of Torture Act (COTA), with responsibility for examining and monitoring the general conditions and treatment of detainees in New Zealand prisons.

This report details observations and findings relating to prisoners who have been considered at risk of suicide and self-harm, who are managed in At-Risk Units (ARUs) in New Zealand prisons; and focuses on the comprehensive inspections of five prison sites. 

Contents of the report include: At Risk Units (ARUs); Inspectors’ analysis of practice in ARUs; Use of mechanical restraints in managing prisoners at risk of self-harm; The use of the tie-down bed in New Zealand prisons; Tie-down beds and mechanical restraints at other prisons; Health services in prisons; Appendix 1. Prisoner quotes on their experience in ARUs.

Summary of findings

My findings may be summarised as follows:

  • Of the 18 prisons across the country, 14 have a designated ARU. At-Risk cells at best can be described as sparsely furnished rooms, which are constantly monitored by a live camera-feed, including the unscreened toilet. Staff of either sex, in the course of their work, can observe At-Risk prisoners in various states of undress. Prisoners’ clothing is removed on admission to ARUs and replaced with anti-rip gowns to minimise opportunities for self-harm.
  • Routines within ARUs are similar to the regimes within management/separates units. At-Risk prisoners are placed in isolation with limited interaction and therapeutic activities.
  • ARU paperwork and directed segregation (for medical oversight) is not always fully completed and lacks specificity and personalisation.
  • Training for staff working in ARUs is basic.
  • Staff interactions with At-Risk prisoners are limited.
  • There were incidences of At-Risk prisoners being restrained on tie-down beds by their legs, arms and chest over prolonged periods. There were incidences of At-Risk prisoners being restrained in waist restraints with their hands cuffed behind their backs.
  • We discovered incidences of tie-down beds and possibly waist restraints being used for behaviour modification purposes at some sites.
  • Prisons were not following their own procedures in respect of the application of mechanical restraints.
  • The interface between Corrections and Regional Forensic Psychiatric Services appears not to be working as effectively as it could. Gaps in service provision were evident.

I consider that the use of the tie-down bed and/or waist restraints in the circumstances of Prisoners A, B, C, D and E2 amounted to cruel, inhuman or degrading treatment or punishment for the purpose of Article 16 of the Convention against Torture. Furthermore, I believe the ability of prison staff to access footage of prisoners undertaking their ablutions constitutes degrading treatment or punishment under Article 16 of the Convention.

Some procedural practices relating to prisoners considered to be at risk of suicide and self-harm were not being adhered to. Gaps in procedural practice and recordkeeping also exist. I urge Corrections to consider new approaches in the care and management of prisoners assessed as being at risk and generally address the issue of the prevention of cruel, inhuman and degrading treatment or punishment. There is much in the way of international good practice in the care of at risk prisoners that incorporates a more person-centred approach, which involves interactive, supportive contact and not mere observation.

At risk units by their very nature tend to create an environment where isolation and minimal regimes are the norm, and where prisoners are unwell and unable to advocate for themselves effectively. This must be mitigated rather than exacerbated.We encourage the Government to action the 2013 SPT’s recommendations and audit the healthcare needs of prisoners. This will enable Corrections to clearly articulate their needs to the Ministry of Health and District Health Boards. My Inspectors will continue to monitor ARUs across the country as part of our inspection mandate and make recommendations for improvement on a prison-byprison basis. By collating our findings and observations from the past 12 months in a more thematic way, we hope the information provided will assist Corrections to implement necessary changes in the delivery of care to at-risk prisoners. 

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