Dr Maria Leitner
Prison health statistics have always made more comfortable reading if you happen to be a fan of the horror genre. Within the last decade, the accelerating decline of prisoner health and prison healthcare has pretty much jumped over a cliff. Let me give you a personal example here to illustrate what this means for the people we choose to incarcerate:
I am a Type 1 (insulin-dependent) diabetic. As many people - although seemingly not some prison health care staff - will be aware, this means that if I am left without insulin there is an all too high likelihood that I will die. And that’s what nearly happened. Having been thrown into prison, I was left without insulin for four days. There are no good excuses here – staff had my medical records, they acknowledged my health status, at my request they dutifully measured my blood glucose and blood pressure every few hours. I’m not sure why, as they simply watched both measurements heading skywards and took no action. I gave them a very clear account of how this would end, just in case their training didn’t cover this basic principle. Still no insulin, no doctor and no rationale given. My daughter brought my insulin kit in to the prison and it was given to health staff. Then it was thrown away. Inevitably I collapsed. I will always be grateful to a local GP called in to respond to the emergency. ‘They might not care if you die – but I’m not going to let that happen.’ He didn’t, I was taken to hospital, but the thin line between surviving and dying had very nearly been crossed. Nor was this a one-off incident. It turns out that the prison had been rapped across the knuckles in an HMIP inspection report for doing exactly the same to another prisoner with Type 1 diabetes just eight months previously.
Unless you happen to be a fan not only of the horror genre but also of capital punishment, surely this level of medical negligence is unacceptable? Nor, sadly, is it unusual. To outline only a very small number of other encounters with prison healthcare that I have been a direct witness to: I have seen prisoners taking their own teeth out to stop the pain as they wait inordinate lengths of time for dental care; prisoners left literally screaming in pain, offered only a single paracetamol, whilst the decision on whether or not to order an ambulance is, as usual, further delayed; I have seen a prisoner suffering an Addison’s crisis being carried on the shoulders of her fellow inmates to the health unit because, over several hours, no member of health care staff was available, or willing, to come and see her. These are not cameos in a film, they are events happening in British prisons in the 2020s.
Disturbingly, I could go on listing the numerous other failures of prison healthcare I have witnessed. But you don’t have to take it from me – on 1st November 2018, the House of Commons Health and Social Care Committee published a report [1] which concluded: “The Government is failing in its duty of care towards people detained in prisons in England… Too many prisoners die in custody or shortly after release… so-called natural cause deaths, the highest cause of mortality in prison, too often reflect serious lapses in care.” When you’ve seen what this means to those on the receiving end of prison healthcare, even this damning conclusion can only be seen as ‘putting it politely’.
Dying in custody
A raft of other reports and official statistics further underscore the increasingly parlous state of health and healthcare in the prisons of England and Wales. By way of example, Ministry of Justice (MoJ) figures [2] for deaths in custody show a near doubling of the annual rate of deaths in prison between 2012 and 2016, followed by a period of ‘levelling off’, but with no substantive reversal of the longer-term upward trend in mortality. In the twelve months to September 2022, the MoJ report a total of 307 deaths in custody in England and Wales, most of which (64.5%) were from ‘natural causes’. These figures are not thought to be driven by Covid, as the previous year’s more substantive figures are likely to have been.
One factor which is a clear driver of total annual deaths in prison remains self-inflicted death, with close to one quarter (22.8%) of all deaths in the year up to September 2022 reported as being self-inflicted. This is one statistic which, unfortunately, has remained intransigently stable over the last decade. To give some perspective here, this means that you are nearly ten times as likely to die from suicide if you live in prison than if you live in the community. That’s assuming that you can dodge death from accidental injury, ‘natural causes’, or violent assault. All of which are at substantially higher levels within prison than outside and all of which have shown an increasing trend over the last decade. Serious prisoner-on-prisoner assaults, for example, increased by 21% to 1,545 just in the twelve months to June 2022. Whilst rates of self-injury have remained broadly stable over time, they are at remarkably high levels in a population which is supposedly subject to strict surveillance. The total number of episodes of self-harm remains currently at upwards of 52,000 per year, in a population averaging around 82,000.
Deaths resulting from assault or suicide, although frankly shocking in number, are perhaps the easiest to account for in the prison setting. Prisons are depressing, over-crowded places where people are intentionally separated from friends, family and community. They are also noisy, dirty places lacking in both privacy and basic resources. Individual and collective tensions inevitably run consistently high. Being in prison essentially equates to living in a permanently stressful situation, with little or no control over either minor or major events and ‘nowhere to hide’. And yes, people come into prison with issues around self-harm and/or aggression, which doesn’t help either. Counter to expectations, however, fewer people find themselves in prison due to aggressive behaviour than you might think and rather more leave with self-harming behaviour than you might hope.
Breaking the cycle
So, leaving the problems of aggression and self-harm for a later discussion, the conundrum to consider here is why, in a comparatively young population, there should be such high levels of mortality from ‘natural causes’. I say ‘comparatively’ here, because, for reasons best known to the ‘powers that be’, we are incarcerating increasing numbers of the elderly, in particular older women [3]. Another topic for another day. Meanwhile, the Health and Social Committee reached a number of conclusions following its Inquiry into prison health and healthcare which might account for the rates of mortality being so much higher in the prison population than elsewhere [4]. These conclusions are reflected in their recommendations, summarised as follows:
Those in prison have a poorer health profile than is the case for the general population, but prison should be used as an opportunity to “break the cycle of poor health and disadvantage”
Ways of measuring the health inequalities of prisoners, in terms of care and outcomes, should be established
Action should be taken to ensure at least equivalent care within prison to that delivered by health services in the community
Liaison and Diversion services established as a result of the Bradley Report in 2009 should be rolled out in all prisons
The decline in Hospital Orders for prisoners with mental health issues should be reversed
Community mental health services should be better resourced
There should be a more robust and better monitored approach to health screening in prison
Prison staff should be better trained to carry out health assessments
The Government should set out a plan to ensure that all prisons are clean and sanitary and that overcrowding is addressed
The Government should also address the need to recruit more prison officers, in order to improve prisoner access to health-related opportunities
Prisoner incentive schemes should be used to encourage healthy lifestyles, not to deny prisoners access to health related opportunities and clear incentive guidelines along these lines should be given to staff
The Government must urgently ensure that all prisoners have access to a reasonable quantity and quality of food which supports health and wellbeing rather than adversely affecting it, the current food budget should be revisited
The number of missed health appointments should be drastically reduced [5]
Substance abuse is a significant contributor to ill health and mortality in the prison population, drugs prevention, reduction and treatment strategies should be improved accordingly and drug-related deaths better reported
The National Prison Healthcare Board should set out set clear reduction targets and measures of success for a reduction in self-injury and self-inflicted death, including improving access to psychological therapies, especially for those with mild to moderate mental health needs and expanding the number of secure hospital beds
A target should be introduced for all local authority areas with prisons to have a memorandum of understanding on the provision of social care in place with each prison in their area
The Government should undertake a thorough investigation of deaths during post-release supervision in the community, including the reasons for the rise in death rate, and should both clarify where responsibility for oversight of such deaths should lie and set out a plan to reduce such deaths
The Committee’s recommendations are comprehensive and hard-hitting. They were also accompanied by what, if implemented, would be a revolutionary whole system approach to health and well-being within the prison system. The clear goal being to break the cycle of disadvantage - a cycle which, frankly, currently dominates our Criminal Justice System from arrest to release and beyond. Cornerstones of this welcome approach include evaluating the merit of applying the tenets of the Female Offender Strategy to other vulnerable prison populations, including those with complex needs. Other key proposals are that the Government, in its plans for prison reform, should place greater emphasis on health, wellbeing, care and recovery, on the basis that this will also help to improve the safety of prisons and reduce reoffending. Further, that “the voice of Her Majesty’s Inspectorate of Prisons (HMIP) must be listened to and acted on”, with Care Quality Commission (CQC) conclusions given greater prominence in HMIP reports. Finally, that joined up thinking should be implemented across those bodies with responsibility for the prison estate. With future planning, including addressing workforce expansion and health and social care commissioning, improved by arriving at a shared view of what a future ‘whole prisons’ approach might look like.
Government in/action
Now, here’s the rub. If you read through the sensible proposals outlined above and then compare them to the Government’s recent and proposed future actions you will note that there are gaping discrepancies between the two. By way of example, the Government has not only not considered the expansion of the enlightened Female Offender Strategy (2018)[6] to other prison populations, but it has reneged on the strategy itself. The main take-home message of the strategy was that the female prison population could, and should, be reduced, with low risk offenders sited in community units better suited to addressing their needs. It’s important to note here that the evidence-based strategy anticipated a reduction in reoffending as a consequence of this move.
Instead, in its recent Prison Strategy White Paper (a response to which is also available on the Open Justice website) the Government set out its intention to massively expand the prison population, building more prisons, primarily with closed not open prison places, for both men and women. It is notable, in the current context, that the White Paper also barely touched on any issues around either physical or mental health, beyond flagging that as more disabled people are being sent to prison, the number of cells with wheelchair access needs to be increased.
Looking at other aspects of the Committee’s proposals and overall strategy: HMIP’s reports continue to flag further failures of prison governance to address issues raised with them in the course of previous inspections; there is little or no evidence of the suggested improvements in healthcare practice being addressed at either the local prison or wider national level and prisoners continue to die at far higher rates than people in the community from self-and other-inflicted injuries in addition to ‘natural cause’ mortality. The future of prisoner health and prison healthcare isn’t looking any brighter right now than it has done over the last decade.
Security vs. Safety
Before ending, I just want to reflect further on the personal examples of prison healthcare given earlier. The proposals and solutions set out by the Health and Social Care Committee are all structural – addressing macro-level and organisational failings. I entirely agree that these need to be addressed. However, my academic work and lived experience of the state of healthcare in the prisons in England and Wales suggests that other factors are also at play. These are human factors if you like, harder to define, identify and to address via national level or structural interventions.
I am not castigating either the majority of healthcare staff or the majority of prison officers here. There are very many humane, forthright and effective members of staff working hard to help the prisoners they are responsible for. But, humans are often directed and bounded by the institutions they find themselves in and prone also to adopt over time the implicit but often unarticulated cultural mores which surround them. I found that, on numerous occasions, staff were willing to accept healthcare practices and health outcomes which they would simply have been horrified by had they been inflicted on their own friends and relatives.
Prisoners become, in most cases unconsciously, perceived as the ‘other’, as dehumanised, as somehow not needing, or deserving the consideration given to patients in the community. In general, there is also too ready an acceptance that the ‘security’ card trumps all other cards in prison. This is probably why the potentially life-saving insulin kit was thrown away.
At a casual glance, the supremacy of security in a prison may seem obvious and logical. When, however, you see how this rule of thumb is applied in practice, you might be given pause for thought. Take, for example, the case of a nearly 60 year old woman, thin, small and frail, in prison for a non-violent offence being chained to a hospital bed whilst given life-saving treatment, with two large officers, one also handcuffed to her, framing the bed. For the sake of ‘security’ she was pulled through the ward with a dog chain attached to one arm and a drip stand attached to the other, dressed only in underwear and a t-shirt in front of the other patients and allowed only to go to the toilet with the chain still attached and the door open. Is this type of practice really entirely necessary?
Another cultural issue is the almost universally applied assumption of guilt. In the prison healthcare context, this is reflected in the seemingly default position that a prisoner complaining of pain or sickness is most likely to be lying. I’m sure that lying does happen, but I have also seen the presumption of guilt resulting in unnecessary and damaging delays to emergency treatment. Neither has the default to a presumption of guilt been entirely absent from deaths in custody Inquiries.
Other equally damaging situations resulting from the interplay between humans and institutions in the prison healthcare context include the natural reluctance to complete difficult and time-consuming paperwork (“let’s just wait and see”) and a morbid fear of taking responsibility in an hierarchical and sometimes unforgiving institution. The nurses who failed to act whilst watching a prisoner approaching a fatal diabetic crisis were not callous, although callousness most certainly exists within prison, they were frightened. Frightened that they would call an expensive ambulance too soon, frightened that the insulin pen might contain drugs, frightened that prison security might see the whole situation from a different perspective.
It is notoriously difficult to legislate into existence compassion, insight and bravery. But maybe we need to go beyond addressing structural issues if we are going to tackle inequalities in health and healthcare in prison and beyond. So, let’s at least commit to exploring the causes at a deeper, more qualitative level.
[1] House of Commons Health and Social Care Committee (2018) Prison Health : Twelfth Report of Session 2017–19 Ordered by the House of Commons to be printed 22 October 2018
[2] HM Prison & Probation Service and Ministry of Justice (2022) Safety in Custody Statistics, England and Wales: Deaths in Prison Custody to September 2022 Assaults and Self-harm to June 2022
[3] House of Commons Justice Committee (2020) Ageing prison population: Fifth Report of Session 2019-2021 Ordered by the House of Commons to be printed on 22 July 2020
[4] The Committee cited standardised mortality rates collated by the Revolving Doors Agency showing a 1.5 times greater risk of mortality in those incarcerated than in the general population, with the risk differential increasing to 2.76 for ex-prisoners
[5] Note here, that, in my experience at least, prisoners are desperate to access health care and missed appointments result most commonly from poor prison administration and prison operations or staffing issues which prevent prisoners from attending.
[6] Ministry of Justice (2018) Female Offender Strategy for women in the criminal justice system Presented to Parliament by the Lord Chancellor and Secretary of State for Justice by Command of Her Majesty
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