When serial killer Harold Shipman committed suicide he became one of the 95 people who killed themselves in prisons in England and Wales last year.
By Margaret Ryan
While his death could not have been prevented, according to the prison ombudsman, hundreds more prisoners are still deemed to be at risk of self harm. What more then can be done to stop someone determined to take their own life?
Last year serial killer Harold Shipman tore off strips of material, made a ligature and hanged himself from his cell window at Wakefield Prison.
His death four years into his life sentences could not have been predicted or prevented, said the prison ombudsman.
Fifty five people have killed themselves in prisons in England and Wales this year
Shipman had previously been on suicide watch after being jailed but was not when he killed himself at Wakefield Prison.
So far this year 55 people - 52 men and three women - have killed themselves in prisons in England and Wales compared with 63 by this time last year.
This is at a time when the number of prisoners has reached an all-time high of 77,008.
Chief Inspector of Prisons Anne Owers told the BBC News website it was clear overcrowding put immense pressure on prisons.
Since April this year a rise in the prison population had coincided with an increase in the number of suicides.
There have been 36 self-inflicted deaths over that period, two of them women, said the Prison Service.
Ms Owers said: "What is more alarming is that 35 happened in local prisons taking prisoners directly from court.
"This is when prisoners are at their most vulnerable, at the early stage in prison and when they are being moved between prisons."
She said it was "difficult not to conclude that overcrowded prisons where prisoners are going in and coming out and moving between prisons was a factor" affecting the number of prisoners committing suicide.
Her role entailed looking a system which she said had been under pressure for a "long, long time".
"People can only cope with that level of pressure for so long," she said.
She said this was keenly felt by staff having to care for new prisoners.
"Prisoners may be arriving with no documents, withdrawing from drugs and staff have to make life and death decisions."
She said there needed to be alternatives to prison, for example better mental health care.
"Suicide is the acute symptom of overcrowding. The chronic symptom is that you cannot do positive work to make it less likely that people re-offend so you are just recycling people."
The Howard League for Penal Reform is calling for more community sentences to ease pressure on prisons.
Spokeswoman Finola Farrant said: "With the present level of overcrowding in our prisons leading to impoverished regimes, it is unsurprising that so many people are killing themselves."
Meanwhile, prison staff struggle to cope with the demands of a high prison population where the majority have mental health problems, according to the General Secretary of the Prison Officers Association, Brian Caton.
"We have got 77,000 people in prison in England and Wales and 90% of them, the authorities say, have got mental health problems.
Shipman was found hanged in his cell
"People should be surprised we don't get more suicides in prisons," he said.
Mr Caton put this down to the vigilance of prison staff.
"For every prisoner who takes their own life, hundreds of prisoners are saved by our members intervening and saving them," he said.
Last year there were 145 resuscitations in prisons after self harm incidents compared with 204 the year before.
About 1,500 people are deemed to be of particular risk of self harm each month, says the Prison Service.
When someone is assessed as being at risk of harming themselves, a complex care plan is put into place with healthcare professionals and prison staff, a spokesman said.
For those deemed to be most at risk this may mean checks as many times as four times an hour.
"It is very difficult to absolutely prevent someone from taking their own life, but that is not to say that the issue is not taken very seriously," he said.
Now a new care plan is being introduced more tailored to individual prisoner needs.
New prisons and new wings are being built at a time when the number of self inflicted deaths has gone down this year compared to this time last year.
But Mr Caton said: "Every suicide in prison is a tragedy for someone, every one is a tragedy for the staff who have to deal with them."
He knows the lasting repercussions of a suicide on prison staff and inmates, having dealt with the aftermath of two people killing themselves.
"You never forget it . The smell - it stays with you. You think 'have I failed? Was there something I could have picked up on?,' " he said.
Consultant forensic psychiatrist Dr John O'Grady said preventing suicide was best tackled by examining the whole prison regime, including ensuring family visits are maintained, drug misuse recognised and that an anti-bullying policy is in place.
"What is needed is a rehabilitative and humane regime where there are good quality relations between staff and prisoners - that means less crowded conditions and access to education, leisure and long term high quality psychiatric care."