Prison healthcare best practice
Absence of clear national replication or sharing of critical learning and improved practices in prison healthcare.
649 items
10 sources
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
Committee recommendation
95match
#8 - Charging bodies would benefit from improved sharing of best practice and expert advice.
We heard charging bodies would value more signposting of where to go for expert advice and support and to learn from others’ experience. DVLA told us that more can be done to share good practice and that it is important to get those responsible for fees together to talk about what they are doing and some of the...
Matched on
terms: best, practice
Committee recommendation
91match
#25 - Support neighbourhood pilot sites to address digital interoperability challenges and share best practice.
In order for the neighbourhood pilots to realise the potential of the innovative model of care they are trialling, the Government should support the pilot sites to address challenges with digital interoperability, for example through sharing of learning and best practise. These learnings should then be collated to support future systems to implement the model, in the event...
Matched on
terms: best, practice
Committee recommendation
83match
#43 - Prisoners are not receiving equivalent healthcare services compared to the wider population
Given the acute needs of those in prison, particularly regarding mental health, it is imperative that prisoners have access to good health and wellbeing services to assist them in properly engaging with rehabilitative programmes. However, despite the principle of equivalence, prisoners are not receiving healthcare on a par with the wider population. (Conclusion, Paragraph 202)
Matched on
terms: healthcare, prison
LGO / SPSO decision
77match
201304654 - Scottish Prison Service
Mr C complained that a prison manager had refused to contact the on-call doctor after Mr C was sick and got something stuck in his throat, causing him chest pain. Mr C said that the prison did not act in accordance with the prison rules because a healthcare professional must be notified of any prisoner whose physical or...
Matched on
terms: healthcare, prison
PFD report
73match
Wilfred Aspinwall
Healthcare provider at HMP Liverpool did not receive critical PPO and Clinical Review reports, hindering effective implementation of recommendations for prison fatalities.
Matched on
terms: healthcare, prison
PFD report
73match
Terence Adams
Inadequate checking and sharing of prison risk assessments, healthcare staff unawareness of risk score protocols, and failure to follow up on missed appointments contributed to a lack of care.
Matched on
terms: healthcare, prison
PFD report
73match
Khairul Rahman
The prison healthcare system lacks robust, accurate documentation of clinical interactions and response times. There is also an unclear and inconsistent application of the NEWS2 scoring system for monitoring patient deterioration.
Matched on
terms: healthcare, prison
Committee recommendation
73match
#35 - Direct College of Policing to collate and share best practices in modern slavery investigations.
In collaboration with the National Police Chiefs’ Council, the Home Office should direct the College of Policing to collate learning from forces that are effective in pursuing and investigating modern slavery and human trafficking and work with the Crown Prosecution Service to secure convictions. This record should be then shared with all other forces.
Matched on
terms: best, practice
Article 2 learning point
72match
WA — HMP Ranby - LP 1
I recommend that, those responsible for healthcare governance at HMP Lincoln and HMP Ranby: identify the requirements of good practice in the specific areas identified below, in the light of the problems that occurred in this case and taking account of NHS and NOMS policies; review their current arrangements and amend them if necessary to meet the requirements...
Matched on
terms: healthcare, practice, prison
PFD report
69match
Zeeyad Hamadi
Inadequate patient weighing and poor medical record-keeping within the prison were noted. There was limited liaison between prison and hospital staff, confusion over prisoner private healthcare policies, and delays in securing bed watch cover.
Matched on
terms: healthcare, prison
PFD report
69match
Andrew Hall
Inadequate communication and documentation of mental health risks, failure to administer prescribed medication, and insufficient patient observation within the prison healthcare unit were identified. Training gaps for staff in risk assessment and ACCT procedures also contributed to concerns.
Matched on
terms: healthcare, prison
PFD report
69match
Kevin Scarlett
The prison service and healthcare failed to assess the deceased's suicide risk, as staff lacked access to proper risk assessment tools or protocols.
Matched on
terms: healthcare, prison
PFD report
69match
Laurence Boyens
Healthcare professionals appeared to misunderstand guidelines for managing drug dependence in adult prison settings, particularly around monitoring blood pressure before administering methadone or buprenorphine, and some nurses did not know when to withhold medication or escalate concerns.
Matched on
terms: healthcare, prison
PFD report
69match
Ian Emsley
Inadequate formal guidance for healthcare staff on assessing re-offending and escape risk contributed to delays in compassionate release or transfer decisions for terminally ill prisoners.
Matched on
terms: healthcare, prison
PFD report
69match
Steven May
Prison healthcare suffered from reception nursing staff failing to consult medical notes, lacking mental health expertise, and incomplete ACCT documents. Inadequate First Aid/CPR training and poor weekend/Bank Holiday healthcare access also posed significant risks.
Matched on
terms: healthcare, prison
PFD report
69match
Thomas Jordan
Communication failures between the hospital and prison healthcare resulted in continued administration of a discontinued drug, as discharge information was not promptly reviewed by prison staff.
Matched on
terms: healthcare, prison
PFD report
69match
Daniel Davey
Healthcare staff's non-routine attendance at ACCT reviews in prison highlighted a gap in collaborative care, requiring closer integration between prison and healthcare services.
Matched on
terms: healthcare, prison
PFD report
69match
Marlon Watson
Healthcare staff at HMP Dovegate demonstrated an inadequate understanding of the ACCT process, which is a significant concern for managing prisoner welfare and suicide risk.
Matched on
terms: healthcare, prison
PPO recommendation
69match
The Head of Healthcare
The Head of Healthcare should ensure that clinical checks on prisoners who are refusing food and/or fluids are carried out and recorded appropriately to ensure risks are managed.
Matched on
terms: healthcare, prison
IMB recommendation
65match
Whatton (2022)
Will the Prison Service, once again, consider substantial refurbishment or replacement of the healthcare facilities so that they match those expected in the community?
Matched on
terms: healthcare, prison
PPO recommendation
65match
The Director and Head of Healthcare
The Director and Head of Healthcare should remind staff that compassionate release applications on medical grounds may be made for prisoners who are incapacitated, and not only for those who are terminally ill.
Matched on
terms: healthcare, prison
IMB recommendation
64match
Altcourse (2021)
The transfer of seriously mentally ill prisoners to appropriate healthcare facilities continues to be a problem, with one particular prisoner spending over 300 days in segregation this year. This case was escalated to a national level. In addition we are concerned about the long-term legacy of the pandemic on prisoners’ mental health. Altcourse is already seeing more seriously...
Matched on
terms: healthcare, prison
IMB recommendation
64match
Peterborough (Men) (2022)
Because of the widespread perception among prisoners that all Healthcare services (Clinical, Mental, and substance misuse) are not up to the standard expected, going forward the prison should prioritise the review and monitoring of Complaints to Healthcare e.g. in the Monthly Clinical Governance Meeting, to ensure that standards are maintained and improved.
Matched on
terms: healthcare, prison
LGO / SPSO decision
63match
201101364 - Scottish Prison Service
Mr C, who is a prisoner, complained because he felt the prison were failing to issue privileged mail to prisoners with a reasonable time in accordance with published standards. Privileged mail is mail sent to a prisoner from their legal representative, the courts and other organisations, such as SPSO. Our investigation highlighted that best practice suggested that prisoner...
Matched on
terms: best, practice, prison
PFD report
61match
Satheeskumar Mahatheaven
Failures in information sharing, multi-agency communication procedures, and inadequate training contributed to an accident within prison services.
Matched on
terms: prison
PFD report
61match
Shalane Blackwood
The prison lacks adequate provision for complex health needs, has insufficient staff for prisoner regimes, faces rife NPS use, and has unclear decision-making tools and staff awareness for physical symptoms alongside mental health issues.
Matched on
terms: prison
PFD report
61match
Dean Saunders
Serious systemic issues include a rigid protocol preventing mentally disordered individuals' transfer from police custody, unclear hospital transfer processes, and inadequate staff training in the ACCT process, compounded by insufficient psychiatric cover in prisons.
Matched on
terms: prison
PFD report
61match
James Frankish
Healthcare professionals lacked understanding of Pica's dangers, and there is no national guidance for its identification, assessment, management, or monitoring for complications like bezoars.
Matched on
terms: healthcare
PFD report
61match
Richard Ormond
A 9-minute delay in upgrading an ambulance response occurred because prison staff initially failed to provide critical information about the patient's condition to emergency services, highlighting a gap in following emergency protocols.
Matched on
terms: prison
LGO / SPSO decision
61match
201507736 - Scottish Prison Service
Mr C complained to the Scottish Prison Service (SPS) about the time it took prison staff to escort him to the health centre located within the prison. Mr C, who has diabetes, was unhappy it took two hours to receive assistance with his insulin pen. He also felt the SPS's response to his complaint was inappropriate. We were...
Matched on
terms: prison
IMB recommendation
60match
Featherstone (2020)
While the performance of healthcare staff appears adequate, there are a number of concerns: attendance at segregation reviews and use of force incidents; the monitoring of self-dispensing of medication held by prisoners; the operation of the healthcare complaints procedure; the thoroughness of mental health reviews and the reporting relationship with general healthcare. Can the Governor discuss these shortcomings...
Matched on
terms: healthcare, prison
IMB recommendation
60match
Dovegate (2021)
Accelerate plans for the conversion of the in-patient unit in healthcare to provide consultation and treatment rooms adequate for the number of residents in the prison. Should it be decided not to proceed with the above, then urgently upgrade the inpatient bath/shower room.
Matched on
terms: healthcare, prison
IMB recommendation
60match
Gartree (2022)
Therefore, can the Prison Service confirm to the Board that the integrated health services at Gartree are achieving the outcomes expressed in various commissioning documents, and that the healthcare is equivalent to the local wider community (i.e. the Market Harborough district)?
Matched on
terms: healthcare, prison
IMB recommendation
60match
Durham (2022)
How will you ensure that all prisoners in reception receive healthcare screening before moving to first night centres (4.1.6)?
Matched on
terms: healthcare, prison
IMB recommendation
60match
Liverpool (2023)
The Board has repeatedly raised concerns around the inhumane length of time prisoners experiencing mental health illness are kept segregated whilst waiting for transfer to an appropriate mental health establishment. A recent example is a prisoner who spent 377 days in the CSU waiting for a transfer, which the Board view as completely inhumane. What immediate action will...
Matched on
terms: practice, prison
IMB recommendation
60match
Hollesley Bay (2023)
The need for hourly observations over prisoners arriving too late to be seen by the healthcare department highlights an important need. Those responsible for transport should be aware of those prisons without 24-hour healthcare provision.
Matched on
terms: healthcare, prison
IMB recommendation
60match
Gartree (2023)
We ask the Minister to explain how the Ministry of Justice perceives the performance of prisoner healthcare at HMP Gartree when compared against the performance specification in the contract.
Matched on
terms: healthcare, prison
IMB recommendation
60match
Dartmoor (2023)
The commitment by the new healthcare provider, Oxleas NHS Foundation Trust, to provide overnight care at a category C prison in Devon - which will be a pathway available to prisoners at HMP Dartmoor - has not yet materialised. What is the progress on this initiative and when will it be introduced?
Matched on
terms: healthcare, prison
IMB recommendation
60match
Bure (2025)
Are there plans to provide specialised units for dementia and geriatric healthcare, given the increasing age profile and fragility of many prisoners? This is especially required in those prisons like HMP Bure that do not have 24/7 healthcare on site.
Matched on
terms: healthcare, prison
Committee recommendation
60match
#1 - Unmet need for mental illness treatment in prisons remains surprisingly high
While there have been improvements in prison mental healthcare, provision is still not adequate. The high unmet need for treatment for mental illness in prisons is surprising and disappointing. Around 10% of prisoners were recorded as receiving treatment for mental illness with one suggestion that as many as 70% may have some form of mental health need at...
Matched on
terms: healthcare, prison
PPO recommendation
60match
The Head of Healthcare at Lewes
The Head of Healthcare at Lewes should ensure that a formal clinical handover is arranged for all complex mental health prisoners before transfer to a new prison.
Matched on
terms: healthcare, prison
PPO recommendation
60match
The Head of Healthcare of HMP Holme House
The Head of Healthcare should ensure that prisoners have access to appropriate therapy services, such as physiotherapy and occupational therapy, following major surgery.
Matched on
terms: healthcare, prison
Article 2 learning point
60match
CR — HMP Swansea - LP Healthcare 4
The date and time of an individual’s transfer to secondary care and discharge back to prison should be documented in the clinical record. This should include any required actions which are identified on discharge from secondary care.
Matched on
terms: healthcare, prison
PFD report
57match
Reggie John
Poor communication and lack of written records between prisons compromised a high-risk prisoner's care. Failures included inadequate review processes and a nurse not accessing or updating crucial risk documents.
Matched on
terms: prison
PFD report
57match
Lee Curran
PPO recommendations for high cholesterol and loss of consciousness protocols were not fully implemented, with NICE guidelines ignored by doctors. Additionally, prison staff lacked training in accurate medical note-taking, leading to incorrect entries.
Matched on
terms: prison
PFD report
57match
John Stabler
The Prisoner Escort Record requires review and redesign. Furthermore, medical records systems need to be consistently available in reception and care areas within prisons.
Matched on
terms: prison
PFD report
57match
Darren Wright
Emergency response was hindered by a staff nurse's inability to locate the incident and a lack of recent CPR training among prison officers due to resource limitations.
Matched on
terms: prison
PFD report
57match
Paul Hardy
Healthcare staff failed to follow instructions for obtaining blood/urine samples for cancer investigation, neglected recommendations for INR monitoring, and did not conduct a Significant Event Analysis.
Matched on
terms: healthcare
PFD report
57match
Daniel Byrne
There were repeated failures to identify and assess suicide risk in newly arrived prisoners, with nursing staff notably absent from initial health screenings and reviews.
Matched on
terms: prison
PFD report
57match
Steven Trudgill
HM Prison Service lacked standardised treatment programs for fire setters with complex mental health issues, and a suggested therapeutic community option for the deceased was not implemented.
Matched on
terms: prison