The excess risk of death for offenders is a public health concern. International comparisons of deaths in penal institutions published by the Council of Europe show wide variability in rates of overall mortality and suicide, sentencing policy, and rates of incarceration between countries.1 However, rates of suicide are significantly higher in prison populations than in free living populations worldwide.2 3 4 5 These findings suggest that referral to prison may not be appropriate for some people and identify gaps in knowledge for healthcare professionals and policy makers.

The recent increase in suicide (registered as self inflicted death) rates in prisoners in England and Wales comes against a background of a steady and downward trend since the turn of the century (table⇓), despite increases in the prison population from around 60 000 in the late 1990s to just over 80 000 by the end of 2007. Deaths from natural causes have risen during this period and at 11.3 per 10 000 have now reached the level …