Yasine Bazine should not have been in prison
At the recent inquest of Yasine Bazine, who took his own life in Wandsworth Prison in 2023, two psychiatrists said that he should never have been in prison. The jury agreed with them that prison was not an appropriate place for Yasine to be detained. The prison psychiatrist was trying to get Yasine moved to a psychiatric hospital at the time of his death.
Yasine Bazine was 25 years old when he was arrested for setting fire to his mattress in his flat. He had a complex mental health history including childhood trauma, psychosis, depression and epilepsy. In 2019 he had an acute mental health crisis. In March 2023 he set fire to his own mattress and then attempted to extinguish the fire. Ambulance, police and fire services arrived. The paramedics noted that Yasine seemed distracted and referred to harming himself but as he seemed calm and cooperative the police saw no reason not to arrest him. It emerged at the inquest that the police control room had a record of Yasine’s previous acute mental health incident but this information was not passed on to the officers who made the arrest and accompanied him to the hospital.
Chelsea and Westminster Hospital
Yasine was taken to Chelsea and Westminster hospital where he was treated for minor burns to his hands and also had a mental health assessment with a mental health nurse. The psychiatrist who was an expert witness at the inquest explained that self-immolation is the most serious form of self-harm. In his view, the fact that Yasine had attempted to self-harm by setting fire to his mattress should have alerted the mental health nurse to the need for a comprehensive mental health assessment to consider whether he should have been diverted from the criminal justice system into mental health care. The nurse did not ask Yasine where he had been treated previously in order to obtain his records, did not seek to understand why he had self-immolated and interpreted his quietness as a response to the police presence. Failure to access medical records is a recurring theme at inquests we attend. A doctor, who did not see Yasine, decided on the basis of a phone conversation with the nurse that Yasine was fit to be charged and assumed he would have a further mental health assessment at the police station. The jury at the inquest concluded that the inadequacy of the psychiatric assessment at Chelsea and Westminster hospital probably contributed to Yasine’s death.
After the hospital, Yasine was taken to a police station to be charged and appeared before magistrates the following morning where he was remanded in custody and taken to Wandsworth Prison. Staff at the police station and the magistrates court relied on the mental health assessment which had been carried out at the hospital.
Wandsworth Prison
At Wandsworth, Yasine was immediately put on to an ACCT (Assessment, Care in Custody and Teamwork) which is the process to look after prisoners at risk of suicide and self-harm. Yasine was initially put under constant observation, but as this is degrading it should only be used for short periods of time and where there is imminent risk. Yasine’s mood fluctuated while he was in prison. The psychiatrist who was an expert witness at the inquest explained that this is not unusual but it means that the assessments within the prison needed to look beyond how Yasine presented at any particular moment. Yasine’s care was shifted to observations twice an hour and then to six “quality interventions” a day. In principle, quality conversations can help reduce the risk of suicide or self-harm if they are carried out properly. It was not clear whether this was the case for Yasine.
The Wandsworth prison psychiatrist was concerned that Yasine was not responding to anti-depressants and decided to get him back to the in-patient mental health wing in Wandsworth (where Yasine had been initially) to assess him properly with the intention of trying to get him transferred to a psychiatric hospital. However, he had to wait for a bed to become available. At his final ACCT assessment, carried out by a prison officer, Yasine was asked if he had thoughts of self-harm and suicide and answered “yes and no.” This answer was not probed further and Yasine’s ”quality interventions” were reduced to three a day. Yasine took his own life shortly afterwards, two weeks after entering Wandsworth Prison. The jury at the inquest concluded that the inadequacy of the prison’s assessment of risk and safety planning probably contributed to Yasine’s death.
Yasine’s family told the inquest that he was passionate and adventurous, with a sense of humour and kind and protective of his family but as an adult he struggled with mental health issues. Following his arrest, no one seems to have tried to understand why Yasine attempted to self-immolate. Assessments of his mental state in the hospital and in prison were inadequate. He should have been in a psychiatric hospital where he could have received more appropriate assessment and care.
