Prisoners in England face dramatically higher rates of avoidable healthcare harms

In 2006, the Department of Health and Social Care took over healthcare provision in prisons in England and Wales with the aim of providing staff, resources, and facilities of at least the same standard as those available to the general public.

But prison overcrowding, understaffing, and increasing rates of self-harm and substance misuse among prisoners have prompted calls for improvements to the quality and safety of prison healthcare.

To gauge the extent of avoidable harms among prisoners due to poor healthcare, the researchers selected 18 prisons in England to reflect the breadth of provision by category, type, and size.

They screened more than 15,000 medical records from which they selected two groups: 6294 prisoners (5896 men; 396 women) considered to be at 'enhanced risk' of healthcare harms because they had two or more long term health conditions, for example; and a random sample of 853 prisoners (832 men and 21 women).

These 7147 medical records were reviewed to identify any unintentional or unexpected events that led to harm during healthcare provision over the preceding 12 months, known as patient safety incidents.

In total, 244 prisoners experienced 247 incidents of avoidable harm, most of which involved discomfort and pain (99; 40%) and delays receiving appropriate healthcare management or assessment (91;37%). Deterioration of medical conditions was also frequently reported (76; 31%).

In all, 209 incidents were assessed as significant--causing moderate or severe harm or death; 171 (69%) were probably avoidable; 204 were possibly avoidable (83%); and 8 (0.1%) were definitely avoidable. In 27 cases, death was directly attributed to the incident.

In one case, a prisoner, who stated that they would hang themselves on arrival at the prison, wasn't referred to the mental health team for support. And no formal action plan (Assessment, Care in Custody and Teamwork plan) was started. The prisoner was moved to the segregation unit, and when unobserved, took their own life in their cell.

In another, advanced cancer was missed, despite the prisoner seeking help several times from the healthcare team with red flag symptoms. This was because the healthcare professionals thought the prisoner's behaviour was prompted by the desire for drugs and failed to refer them. They ended up needing emergency surgery and a prolonged stay in intensive care.

Based on their findings, the researchers estimate that the maximum incidence of all avoidable harms in prisons in England might be as high as 3412 per 100 000 patient-years. In other words, 34 in every 1000 prisoners would experience avoidable harm every year.

This is an observational study, based on 18 prisons, and as such, no firm conclusions can be drawn about cause and effect. The researchers also acknowledge that the medical records they reviewed were often incomplete and entries sparse or of poor quality.

Nevertheless, better management of long term conditions in prisons and greater support for prisoners at risk of self-harm and suicide is needed, they say.

"Efforts in prisons will not give prisoners 'special treatment' not afforded to the rest of the population, but will reduce health inequalities faced by a population with complex healthcare needs," they write.

But the differences in the risk of healthcare harms between prisoners and the general public warrant urgent action to tackle the systemic failures contributing to harm, they insist.

"This stark disparity underscores the urgent need for government and policy action. Delivering safe, equitable healthcare in secure environments remains a major challenge that demands focused attention," they conclude.

Source:

BMJ Group

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