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A study aiming to develop and validate a new structured risk assessment approach for people in prison who are at risk of self-harm and suicide.

Why is the RAPSS study necessary?

The rate of self-harm and suicide amongst people in prison is substantially higher than people who are not incarcerated. Current practice in England and Wales places people in prison who self-harm or express suicidal ideation on a suicide risk management plan called an ACCT (Assessment, Care in Custody and Teamwork). While a person in prison remains on the ACCT, there is evidence to suggest the immediate risk of suicide and self-harm is reduced. However, following closure of the ACCT, the risk of self-harm remains high for the few months. The RAPSS project aims to understand modifiable risk factors and develop a risk assessment model or tool that could inform professional decision-making around the time that closing an ACCT is considered. If a risk assessment model can accurately stratify the risk of future self-harm in an individual, this could direct limited resources towards those individuals who are most likely to need them. It can also allow for the identification of needs that could be a focus of follow-up work.

What is the aim of the RAPSS study?

The RAPSS study aims to develop and validate a new structured risk assessment approach. We aim to do this in two stages. The first stage involved developing a model. We have collected static and dynamic variables on 771 people in prison who have had recently had an ACCT closed. We have then collected data on whether these individuals had their ACCT reopened in the subsequent three months after closure. Analysis of this dataset should identify the variables which are most associated with an elevated risk of ACCT reopening, these will then be analysed in multivariable models to identify a parsimonious model, with an emphasis of modifiable factors.

In order to validate this model, which is a necessary and key step in research using these methods, we will test its performance in a new cohort of people in prison who are on ACCTs. To do this we have collected data on a new group of approximately 400 participants, collecting the necessary data on risk factors to populate the model, and the outcome measure of whether the prisoner had an ACCT reopened in the three months after ACCT closure.

In addition to the development (Stage 1) and validation (Stage 3) of the risk assessment tool, the study will also conduct interviews with people working in prison who might use such an approach should it be implemented in the prison setting, such as safer custody teams and also with people in prison (Stage 2). The purpose of these interviews is to assess whether the data that will be required for implementing the tool will be easily accessible to the safer custody team and whether the prisoners and prison staff would be comfortable answering and asking questions respectively that are required to populate the tool. This part of the project will be reported separately from the development and validation of the tool.

It is important to emphasise that this project is not developing any approach or system to replace the ACCT. It will provide new evidence on risk factors at the end of the ACCT, and whether they can be organised into a model that can complement existing practices.

Who is funding the research?

This study is funded by the HTA Programme of the National Institute for Health and Care Research (NIHR) and has received ethics approval from an independent medical research ethics committee.

Current Progress

Data collection for Stage 1 was completed in August 2022, and for Stages and 2 and 3 in June 2023. Analyses have been completed and findings are being written up.


Core project team:

Seena Fazel, University of Oxford    

Jenny Shaw, University of Manchester

Jane Senior, University of Manchester

Thomas Fanshawe (senior statistician), University of Oxford

Amanda Perry, University of York


Oversight Committee:

Tim Amos, University of Bristol/Avon and Wiltshire Mental Health NHS Trust, Chair of Oversight Committee

Lucy French, PPIE representative

Nigel Blackwood, KCL

Mike Horton, University of Leeds

Huw Stone, Surrey and Borders Patnership NHS Foundation Trust



Nat Wright, Spectrum Health

Keith Hawton, University of Oxford

Tammi Walker, University of Durham

Artemis Igoumenou, UCL



Leanne Heathcote, University of Manchester

Sarah Morriss, University of York

Claire Muller, University of Manchester

Ellie Thompson, University of Manchester

Leen Farouki, University of Oxford

Constance Hurton, University of Oxford

Alex Lewis, University of Oxford