The outcome of a national safety investigation into the management of chronic health conditions in prisons has been published. This follows the Healthcare Safety Investigation Branch’s (HSIB) investigation into the case of Martin, a 43 year-old inmate, who suffered multiple seizures after his epilepsy medication was not transferred with him to a new prison.
Each day 120 prisoners with ongoing medication needs are moved between prisons – this accounts for 44 per cent of the whole prison population.
HSIB reviewed the entire event, from the start of Martin’s internment through to the moment where his medication was acquired by the Category C prison he was moved to. The investigation identified opportunities and solutions that could be applied across the system to reduce the risk to prisoners being transferred between prisons and to those being released into the community without crucial medication.
Four findings
- NHS England/Improvement Health and Justice Regional Commissioning Teams apply varying levels of oversight and governance over offender healthcare services – the result: poor incident investigations and reports.
- CQC and HMIP inspections focus more on prisoners being released into the community than on the routine transfer of prisoners between prisons.
- Lack of interoperability of the two main IT systems in use in prisons – one for healthcare records and one for the operational requirements of prisons which makes it difficult to share essential information across the prison service.
- Limited authorised prescribers in prison healthcare departments, particularly during core hours when transfer occurs may put prisoners with medication requirements at risk.
HSIB’s safety recommendations for the regulator, commissioners of prison healthcare services and the National Prison Healthcare Board
- CQC: to amend its inspection criteria to ensure that inter-prison transfer processes are covered in the inspection schedule.
- NHS England/Improvement: to review how they monitor and assure the provision of healthcare in prisons to reduce variability in standards, particularly in the areas of incident reporting and investigations.
- National Prison Healthcare Board: oversee work to implement interoperability between the two separate IT systems (prison and health) enabling the appropriate sharing of information across the prisons service without impinging on the confidentiality requirements of both systems.
We now await these organisations responses to HSIB’s recommendations.
Kevin Duce, Principle Associate
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