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Healthcare in the justice system must be improved to prevent more prisoners dying prematurely, warns a new report by the Royal College of Nursing and a government advisory committee.
It comes amid a rise in the number of natural deaths in custody in England and Wales over the past 10 years, from 114 in the year to June 2010 to 168 in 2019, with a high of 190 in 2016.
“There is a general feeling among nursing staff that healthcare provision in prisons comes with a low status”
RCN and IAP report
In the year to June 2020, 179 deaths from natural causes were recorded, which will include those that occurred during the initial peak of the coronavirus pandemic.
The upward trend is reflected in the death rate per 1,000 prisoners, which went up from 1.3 in 2010 to 2.0 in 2019 and 2.2 in 2020.
The report – titled Avoidable natural deaths in prison custody: putting things right – warned that the high number of deaths in prison was “not just a reflection of an ageing prison population”, and that many were probably preventable.
The average age of natural death in prison is 56, compared with 81 in the general population, with the most common causes being heart disease followed by cancer. More than a third are among people aged between 35 and 54.
The report is authored by the RCN in partnership with the Independent Advisory Panel on Deaths in Custody (IAP), which advises government on issues related to deaths in people who are detained.
They sought to find out how early natural deaths could be avoided and what improvements could be made to the health and care service for prisoners.
The report draws together findings from an expert roundtable, prisoner consultation, previous inquires on the subject and wider research.
Problems highlighted in the report included a failure to recognise deteriorating conditions in prisoners; variation in clinical recording systems and processes; and lack of healthcare equipment.
Prisoners were too often missing or facing long waits for their healthcare appointments. Some individuals were not attending due to fear of bullying, while others were not able to attend due to the absence of staff escorts.
Meanwhile, older people in custody were judged as receiving “sub-optimal access to appropriate healthcare”, with conditions like dementia sometimes going undiagnosed.
“These deaths may be prevented if there is adequate care, particularly for those prisoners with long-term chronic conditions”
The IAP also received anecdotal reports of healthcare staff “ignoring” do-not-resuscitate (DNR) decisions for older terminally ill patients.
“There appears to be minimal guidance regarding the use of DNRs within the prison healthcare system which could explain the varying practices between prisons,” it added.
In addition, it said there was a “pressing need” to review policy and practice in relation to what it described as “the cruel and inappropriate use of restraints, from shackles to escort chains, when escorting, or supervising in hospital, people who are frail and seriously ill”.
Serious concerns were also raised in the report about the handling of applications for early compassionate release among people with health conditions.
However, achieving positive change in prisons was difficult because of the “entrenched closed culture” that was “worsened by the current climate of resource limitations”, said the report.
Roundtable delegates who gave evidence to the review highlighted issues around an “on-going lack of communication and mutual understanding between prison and NHS systems with disconnect between healthcare and wing staff”.
“One delegate explained that amongst some nursing staff there has been a development of a more security driven behaviours entwined with therapeutic attitudes,” it added.
Issues around staff recruitment and retention, including among nurses, were also flagged in the report with lack of awareness of opportunities in the prison system.
Staff shortages meant agency workers were often employed, but were “usually inexperienced in prison healthcare”.
“There is a general feeling among nursing staff that healthcare provision in prisons comes with a low status,” added the report. “For students, forensic placements are not considered a core competency.”
A series of recommendations were made and have been sent to prisons minister Lucy Frazer, and Nadine Dorries, minister for patient safety, suicide prevention and mental health.
- Enhancing the profile of healthcare careers in prison and allowing more placements for students;
- Implementing the “dying well in custody” charter to deliver uniform palliative care;
- Developing a dementia care pathway including making all prisons dementia friendly;
- Creating of a joint health and justice older persons strategy;
- Reassessing the policy on DNRs;
- Overhauling the process of compassionate release from custody;
- Improving standards of post-death investigations.
Ann Norman, the RCN’s professional lead for criminal justice, said: “We are seeing a growing number of natural deaths in custody and this has now reached an unacceptably high level.
“These deaths may be prevented if there is adequate care, particularly for those prisoners with long-term chronic conditions,” she said.
“The government must act now to make sure that prisoners’ health is properly managed, as it would be in the community.”
In response to the report, a government spokesperson said: “An aging prison population poses particular challenges and we are developing a strategy that specifically addresses the needs of this group.”