A novel approach to the assessment of repeat self-harm in prisoners: development and validation of a tool to bridge assessment and treatment (RAPSS).

Background: Repetition of self-harm in prisoners is common but approaches to assess and manage risk of repetition are inconsistent and unstructured. Objective: To develop and validate a risk model for repeat self-harm in people in prison, and test feasibility and acceptability. Methods: In seven English prisons, we identified 754 people aged over 17 who had been placed on a suicide risk management plan (known as an Assessment, Care in Custody and Teamwork) after a self-harm episode or elevated risk. We developed a multivariable model to estimate risk of repeat suicidality at 3 months using routinely collected sociodemographic, clinical and prison-related factors, which were tested using Cox proportional hazards models. We tested 25 potential risk factors comprising sociodemographic factors, clinical history and treatment, and criminal records using routinely collected information. In a prospective validation sample of 390 people from 13 prisons, we tested this model to assess risk of repeat suicidality at 3 months across a range of performance measures. TRIPOD guidelines were followed for the design and reporting of this work. In a parallel study, we qualitatively ran separate focus groups for prison staff and people in prison to examine practical issues relating to the potential use of a new tool, and synthesised themes. Findings: In the overall final sample of 1144 people in prison [966 (84%) men, mean age 33 years], 22% had the outcome of repeat suicidality over 3 months. The final risk model consisted of 9 factors, including sex, calendar age, and features of recent suicidal behaviour. Calibration and discrimination were similar in both development and validation samples, with O:E ratio = 1.09 (95% confidence interval 0.88 to 1.35) and c-statistic = 0.66 (95% confidence interval 0.60 to 0.72) in external validation. At a 25% cut-off, sensitivity was 58% (50-66%) and specificity 72% (68-75%) in external validation. The tool (Risk Assessment for people in Prison at risk of Self-harm and Suicide or RAPSS) is available as an online risk calculator at https://oxrisk.com/rapsstrial/ and could be used towards the end or on completion of an existing suicide risk management plan. The qualitative study, conducted with multidisciplinary staff groups and two prisoner groups (one male and one female), led to eight themes being identified. Two prominent ones were staff saying that they would be keen to use the tool as a way to identify needs and signpost to other services, and people in prison explaining that any risk tool could help build rapport with their offender manager and support them to access psychological treatments and other services. Conclusions: We have developed and externally validated a brief structured tool that could act as a therapeutic bridge between the closure of a suicide risk management plan and aftercare provision for people at risk of repeat self-harm in prison. Future work: Feasibility work examining how to implement the Risk Assessment for people in Prison at risk of Self-harm and Suicide (RAPSS) tool into practice is necessary, and linking interventions to risk scores. Limitations: The risk model did not test symptoms as possible factors as these were unreliably documented. Funding: This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number 16/159/09.