Sue McAllister CB
Prisons and Probation Ombudsman
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Health, Social Care and Sport Committee National Assembly for Wales Cardiff Bay Cardiff CF99 1NA
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22 October 2019
Dear Committee for Health, Social Care and Sport
Re: Inquiry into the provision of health and social care in the adult prison estate
I understand that the Health, Social Care and Sport Committee is welcoming written submissions for the above inquiry.
My role
My office carries out independent investigations into deaths and complaints in custody. The PPO’s role and responsibilities are set out in detail in our terms of reference[1].
We have two main duties:
- To investigate complaints made by prisoners, young people in detention (young offender institutions and secure training centres), offenders under probation supervision and immigration detainees.
- To investigate deaths of prisoners, young people in detention (including residents in secure children’s homes), approved premises’ residents and immigration detainees due to any cause, including any apparent suicides and natural causes.
The purpose of these investigations is to understand what happened, to correct injustices and to identify learning for the organisations whose actions we oversee so that we can make a significant contribution to safer, fairer custody and offender supervision.
The PPO does not investigate complaints that relate to the clinical judgment of medical professionals. However, there are complaints that touch upon issues of health and social care and, of course, our fatal incident investigations will always include a clinical review which we commission from medical professionals.
In relation to prisons, my role extends across England and Wales.
My submission to the inquiry into the provision of health and social care in the adult prison estate
HMP Parc & Healthcare Complaints
HMP Parc is a private prison operated by G4S. The primary care services at HMP Parc are also delivered through a contract with G4S meaning that healthcare is provided by doctors and nurses who are employed and contracted by G4S.
In 2017 we concluded an investigation into a complaint from a prisoner at HMP Parc about there being nowhere outside of the prison to escalate his healthcare complaint to. It became apparent during our investigation that this was the case.
Complaints about the clinical judgement of medical professionals is outside the PPO’s remit and therefore we are unable to consider such complaints about healthcare at HMP Parc. The Parliamentary and Health Service Ombudsman (who consider such complaints relating to English prisons) has no remit in Wales, and the Public Services Ombudsman for Wales has been unable to investigate because healthcare at HMP Parc is privately run.
Following the investigation, we recommended that G4S, the Local Health Board and the HIW explored introducing an independent element to the complaints process for prisoners at HMP Parc.
Following our recommendation, an escalation process was introduced where complaints about healthcare at HMP Parc can be submitted to the Director of Strategic Support, Administration and Assurance (HMPPS in Wales) who is independent from G4S. The Director can request that an independent healthcare professional reviews the complaint if necessary.
It is encouraging that our recommendation was implemented so that the complaints will now be considered by someone outside of the establishment. However, I am still not convinced that the healthcare complaints process is as clear and thorough at HMP Parc as it is for prisoners in the rest of Wales and England. Ultimately, it appears that it is a non-clinician deciding whether a complaint should be looked at by someone with medical expertise.
HMP Parc and Healthcare Inspections
Healthcare Inspectorate Wales (HIW) inspects the majority of prison healthcare services. However, we are aware that primary healthcare provision at HMP Parc does not fall under the remit of the HIW because the healthcare is privately run. It is concerning that there appears to be no clear inspection oversight for the primary healthcare provision at HMP Parc. This also confuses matters when we need to escalate concerns or recommendations relating to the provision of primary healthcare at HMP Parc, as it is unclear who would have oversight and responsibility for them. I would ask that this is addressed.
Fatal Incident Investigations
HIW undertake the clinical reviews that form part of our investigations into fatal incidents in prisons in Wales. I understand that HIW provided the inquiry with a breakdown of the number and type of fatal incident investigations in their evidence. Therefore, I will not repeat those figures here.
Deaths from natural causes account for the majority (54%) of our fatal incident investigations, and the majority of these in 2018/19 were of men over 60. This is largely explained by the increase in older prisoners and associated age-related conditions. Our natural cause investigations focus in particular on the need for prisons to provide appropriate healthcare at a level equivalent to that which could be expected in the community.
The majority (31%) of the recommendations we have made following a natural cause death related to healthcare provision such as ensuring attendance at hospital appointments and avoiding delay, robust record-keeping and additional training for staff for particular medical conditions.
I am concerned that there have been two investigations into deaths at HMP Cardiff in 2019 where we have found that the healthcare provision was not equivalent to that in the community. The Governor, the healthcare providers and the NHS Commissioners need to address this worrying situation as a matter of urgency.
Between 2014 and 2018 we opened 16 investigations into self-inflicted deaths that occurred in Welsh prisons. Following our investigations into self-inflicted deaths across the prison estate, 24% of the recommendations we made related to suicide and self-harm prevention. This included training for staff in assessing risk, holding multi-disciplinary case reviews, recording all known risk factors and sharing relevant information.
It is important that prisoners receive effective continuity of care when they move into custody from the community, or from prison to hospital and back again. It is also important that they receive effective continuity of care if they move between Welsh and English prisons. Accurate record-keeping and good information sharing practices are crucial to this.
Disabled prisoners and ageing prison population
I have already referred above to the increase in older prisoners. In June 2017, we published “Learning from PPO investigations: Older Prisoners”[2]. This report noted that the challenge to HMPPS is clear: prisons designed for fit, young men must adjust to the largely unexpected and unplanned roles of care home and even hospice.
The proportion of older prisoners has been growing over the past decade and a half. In absolute terms, the number of prisoners over the age of 50 has nearly trebled, from more than 4,800 in 2002, to nearly 12,600 in 2016.
The overall demographic shift and increase in life expectancy in the general population will lead to an ageing prison population. This makes it all the more pressing that prisons have in place effective policies and processes that will allow them to ably care for ill and disabled prisoners.
One area for consideration across the prison estate is ensuring that cells and facilities are designed to accommodate disabled prisoners on normal location (and not just in healthcare centres). Earlier this year we investigated a complaint from a prisoner at HMP Berwyn in which he was complaining that his disabled cell was not properly equipped with shower facilities that were suitable for a wheelchair user. This demonstrates that consideration needs to be given to the provision of cells being designed to accommodate disabled prisoners.
Other areas to be considered include:
- Consideration of the resettlement needs of older prisoners (which are likely to be less about employment and more about coping strategies and location close to families).
· The provision of suitable environments within prisons to provide intensive palliative care and end of life care for terminally ill prisoners, and the development of close relationships with local palliative care services, including local hospices.
- Analysis of the rates of certain illnesses and disabilities within the prison population so that provision can be planned, such as ensuring staff have received appropriate training for particular medical conditions.
- The social care needs of older prisoners and whether there is a need for co-commissioning with Social Services.
Prisoner mental health
In January 2016, we published “Learning from PPO investigations: Prisoner mental health”[3]. Mental ill health is closely associated with the depressingly high rates of suicide and self-harm that we have seen in prisons in recent years.
There is no doubt that managing mental ill health is a significant challenge for HMPPS. Some of the most difficult and challenging behaviour in our prisons is displayed by distressed people with mental health problems trying to communicate that they need help.
Our 2016 report included 25 lessons for HMPPS and the MoJ. The commissioning of adequate mental health provision for prisons and the ability to transfer prisoners to secure hospital accommodation when necessary, are clearly crucial.
Drug detoxification
Some of my fatal incident investigations have raised concerns with the drug detoxification programme in Welsh prisons. Unlike English prisons, as far as we are aware, Welsh prisons do not offer an integrated drug treatment system (IDTS) for prisoners who arrive dependent on substances, and they do not routinely offer opiate medication for maintenance or detoxification. There are some concerns about the impact this could have on prisoners who transfer from an English prison to a Welsh prison. We have previously raised this with the Welsh Affairs Committee.
The Welsh Affairs Committee published a report in May 2019 on “Prison Provision in Wales”.[4] In this report the Welsh Affairs Committee said that they:
“…heard during prison visits that prisoners coming to the Welsh estate from English prisons posed a disproportionate problem, especially in relation to security, as a result of prisoners’ expectations that they would be prescribed substitute medication.”[5]
The Welsh Affairs Committee made the following recommendation in their report:
“We respect the Welsh Government’s decision to have a different drugs policy than England. However, this gives rise to particular issues when prisoners transfer from the English to the Welsh estate. To address these issues, we recommend that HMPPS work with NHS Wales to develop a transition arrangement for prisoners transferring from English prisons on arrival at Welsh prisons. This should be based on clinical advice, providing the necessary support until prisoners are fully integrated into the substance misuse programmes used in prisons in Wales. This arrangement should be in place by the end of 2019. We further recommend that more data should be collected and evaluation undertaken to gain a full picture of treatment differences between Wales and England, to include both opioid substitution psychosocial approaches and prescription arrangements.”
I would fully agree with this recommendation from the Welsh Affairs Committee.
I hope that this is helpful. Please get in touch if you require any additional information.
Yours sincerely
Sue McAllister CB
Prisons and Probation Ombudsman