Annual Report 2012: Spain’s National Preventive Mechanism Typology Prison Accidents Hospital Total 4 1 5 Other illnesses 34 60 94 TOTAL 98 69 167 Source: In-house compilation based on data supplied by the SGIP. Table 33. Deaths of inmates at prisons under the authority of the Government of Catalonia in 2012 Typology Total Drugs 1 Suicide 6 Other causes 15 Natural causes 13 TOTAL 35 Source: In-house compilation based on data provided by the Justice Department of the Government of Catalonia. Whenever the Ombudsman Institution learns of a death, it carries out an ex officio investigation During the inspection visits the monitoring of implementation of the Suicide Prevention Program was examined 88 Note should be taken that whenever there is knowledge of a death in such cir­ cumstances, the Security and Justice Department of the Ombudsman Institution files an ex officio complaint, as explained in the appendix of this report. Further­ more, in the course of the NPM inspection visits, the files of cases of deaths in the prison during the year are reviewed. Said review was performed at the prison of Araba/Alava, where there were two deaths in 2012. The first one occurred follow­ ing hospitalization of the inmate, so that the hospital’s medical records were con­ sulted, but not the death certificate. In the second case, the inmate was found dead in his cell. Given the characteristics of the incident, it was reported to the courts. A Magistrates’ Court intervened and ordered that a judicial autopsy be performed, the report of which was not consulted at the time of the inspection. 99. The World Health Organization considers persons deprived of liberty as a group at high risk for committing suicide. This implies that the Penitentiary Ad­ ministration must take all possible measures to avoid suicidal conduct and regu­ larly assess their effectiveness to improve the quality of said measures. For this purpose, during the inspection visits the monitoring of implementation of the Office of the Secretary General for Prisons’ Suicide Prevention Program (abbrevi­ ated as PPS in Spanish) is examined. At the Murcia II prison, for example, it was noted that the program was being applied with good results, but that specific scales should be used as part of the routine to assess the risk of suicide during the medical examination upon an inmate’s admission to the prison. In turn, at the A Lama prison (Pontevedra), it was noted that the risk assessment instrument was only applied in cases in which there was a previous history or the physician sus­ pected that there could be psychiatric symptoms. A more rigorous system of ob­ servation of the mental state of inmates should thus be implemented, in particu­ THE OMBUDSMAN OF SPAIN