IMB Health Notes – October 2019 (Pt. 1)

The IMB reports published during the early part of October 2019 were from these establishments:

  • HMP/YOI Winchester
  • HMP Usk & Prescoed
  • HMP Liverpool
  • HMP Huntercombe
  • HMP Whitemoor
  • HMP Belmarsh
  • HMP Stocken

IMB evidence comes from observations made on rota visits, scrutiny of records and data, attendance at various meetings, informal contact with staff and prisoners, prisoners’ applications and monitoring of areas of concern.

Here are some of the more interesting points contained within those reports, pertaining to health and wellbeing:

IMB Report – HMP/YOI Winchester

Reporting period – 01 Jun 2018 to 31 May 2019.

  • High levels of self-harm continued to be an area of deep concern. There were 772 reported incidents during the year, an increase of over 60% compared with the previous year, which is even greater when account is taken of the reduced prisoner numbers since January. 88% of the incidents were reported as cutting. There were 49 incidents of attempted hanging or self-strangulation compared with 20 in the previous year, described as a particularly shocking increase, with nine in April 2019 alone.
  • The number of ACCTs in 2018/19 was 973, compared with 931 in 2017/18. An increase in the number of ACCTs across the two years, despite the decreasing prisoner population of 2019.
  • There were typically up to 40 ACCTs open at any one time. Reasons include the much higher number of prisoners arriving with self-harm markers, and the tendency of staff to be more aware and/or risk averse.
  • MDT results show an ongoing decline in positive results from 35% in September 2018, when the regime changed, to 7% in March 2019.
  • Increases in searching uncovered a significant amount of spice (estimated to be worth £150,000 between January- April 2019 alone), cannabis and tobacco.
  • During this reporting period, there 6 six deaths in custody at HMP Winchester. 4 deaths were self-inflicted (compared to one in the previous year) and 2 were from natural causes.
  • Healthcare staffing levels have remained highly problematic throughout the year, especially in nursing. The primary care nursing complement rose from 49 to 65, but nationwide nurse shortages have meant that the vacancy level was 49% in May 2019. the service still struggles with recruitment and retention, and suffered further from sickness levels.
  • A recent re-profiling exercise has introduced paramedic staff and emergency care technician roles, who were deemed to be easier to recruit.
  • Every new prisoner has an MH assessment within 24 hours.
  • Lack of high-quality clinical spaces for consultations, particularly on the wings, remains a major problem, increasing the need for escorts/runners for prisoners to access healthcare. One consequence is the increased likelihood of missed appointments, late arrival or refusal to attend, thus lengthening waiting lists. Staff feel demotivated by being unable to offer the appropriate quality of professional service. The commissioner has allocated funds to establish clinic rooms. Responsibility for deep cleaning of Healthcare clinical spaces is not covered in contractual arrangements compromises the control of infection. The standard of healthcare showers and sinks remains inadequate.
  • The misalignment of the prison regime and healthcare/dental clinic times also adversely impacts on the number of treatments provided, as well as DNAs.
  • The welcomed increase in healthcare services available to prisoners has created its own additional demand for escorts. An exercise is under way to see how escorts/runners can be used optimally. Contracting for more in-house services, such as the recent provision of ultrasound, would reduce the prison’s burden of providing escorts for external clinic visits.
  • Lack of prison officer supervision at hatches during medicine rounds is a significant issue on all wings, even though hatches are supposed to be closed if an officer is not available. This reportedly results in high levels of verbal abuse and risk of misappropriation of drugs. Steps are being taken to mouth-search every patient after medicine rounds.
  • The number of prisoners with social care needs has put pressure on bed availability in Healthcare, as the cell design in the main wings does not properly accommodate prisoners who use wheelchairs. The transfer of prisoners to other prisons with more suitable accommodation has been challenging.
  • The process for handling prisoners’ complaints has improved, given that the NHS criteria differentiating enquiries, concerns and complaints are not generally understood by prisoners.
  • 17% of applications received by the IMB related to healthcare issues indicates a continued sense of prisoners’ dissatisfaction with the service.
  • Healthcare applications to the IMB decreased to 68 from 95 when compared to the previous reporting year.

Full IMB Report – HMP/YOI Winchester

IMB Report – HMP Usk & Prescoed

Reporting period – 01 Apr 2018 to 31 Mar 2019.

  • The board consider that healthcare continues to provide a good service but is always busy. It works well with other departments and partners.
  • There has been progress in the “End of Life” palliative pathway but not as much as anticipated.
  • There is still a problem with diverted medication, although there have been fewer reports of this practice now paracetamol and ibuprofen are available with a token from the vending machines, outside the hours of healthcare provision. The reclassification of some analgesia, which is no longer allowed in possession at Usk, has also helped reduce the problem. Regular medication checks continue.
  • The were 2 Deaths in Custody, both of natural causes. Only 1 of these Clinical Reviews subsequently led to recommendations, which have since been implemented.
  • There were no healthcare applications to the IMB, a decreased from only 1 when compared to the previous reporting year.

Full IMB Report – HMP Usk & Prescoed

IMB Report – HMP Liverpool

Reporting period – 01 Jan 2018 to 31 Dec 2018.

  • In the year, 207 prisoner on prisoner acts of violence were recorded and 10% of these were regarded as serious. A further 64 acts of violence were directed at officers by prisoners and 12.5% of these were considered to be serious.
  • The number of ACCT’s opened in the year from January to December 2018 was 1114. Analysis revealed that 47% of ACCT’s opened in any month occurred in reception.
  • In 2018 there were 7 deaths in custody. Of these 4 were apparently self-inflicted, 2 prisoners died of natural causes and one died as a result of an incident where a parcel of drugs he had ingested ruptured inside him.
  • Movements through reception for 2018 were 6975 incoming receptions, and 7269 outgoing transfers/releases/discharges.
  • Clinical and management roles are clearly defined. Healthcare staff report that the Healthcare Governor and Clinical Lead provide accountability and clear direction.
  • The inpatient unit is well-equipped and clean, with 22 cells, some often out of commission and not repaired within a reasonable time. Two are being converted to alcohol dependency cells. All patients are reviewed weekly by the Multi-Disciplinary Team which includes medical and psychiatric clinicians.
  • Key Performance Indicators demonstrate improvements, but the waiting time for a GP appointments is over 3 weeks. Waiting times for dental appointments reduced from 14 days to 3 days. Following complaints from prisoners about missing internal appointments they are collected from their cells or workshops by prison officers – depending on resources.
  • Since the CQC inspection in 2018 the prison is making an effort to meet the in-possession medication Key Performance Indicator, but it is not widely accepted that this is desirable.
  • In 2018 an average of 10 prisoners were in receipt of 2–40 hours of social care per week. Wheelchair access to workshops and showers is poor.
  • The wait for transfer to secure hospitals has reduced from 16 weeks to around 4 weeks, but due to the triage system some may still wait up to 10 weeks. Some are on constant watch, requiring significant prison resources.
  • There is still a high workload for mental health staff as significant numbers of prisoners suffer from mental ill health, and due to lack of beds prisoners with serious issues are often kept in the CSU unit. They are visited at least twice daily by mental health professionals, but otherwise are cared for by prison staff, again using significant resources.
  • Healthcare applications to the IMB decreased to 31 from 53 when compared to the previous reporting year.

Full IMB Report – HMP Liverpool

IMB Report – HMP Huntercombe

Reporting period – 01 Jan 2018 to 31 Dec 2018.

  • The number of violent incidents fell by 50%, with an average of just over 8 per month being recorded.
  • The number of ACCTs opened fell by 17%, and averaged just over 10 per month. Most of these being closed within 2 weeks.
  • 2 GPs hold surgeries totalling 25 hours on Monday, Thursday and Friday; on Tuesday and Wednesday GPs remain on-call. There are no GP surgeries on Saturday and Sunday.
  • There are up to 2 dentistry sessions per week. In the 2016 and 2017 Annual Reports the Board noted backlogs for dentistry services; in 2017 extra clinics were provided to clear that year’s backlog. During the reporting year there was a backlog for dentistry.
  • The smoke-free policy was phased in and completed successfully in February. Initially, there was a high take-up for the smoking cessation programme; demand subsequently reduced; the smoking cessation programme and non-drug therapies (NDT) programmes continue to be available.
  • Towards the end of the year, the NHS altered its recommended national policy regarding initial screening of prisoners at reception. The new process requires in-depth screening, lasting up to 4 minutes per prisoner, in reception on the day the prisoner arrives at Huntercombe. Previously, this would have been done in-cell on the second day, following initial screening in reception on the day of arrival. The consequence of this change is hold-ups in processing prisoners in reception.
  • During the reporting period, healthcare was consistently short of permanent nursing staff. The permanent headcount budget was 5.4 primary care nurses; of these 1.7 were directly employed with the remaining 3.7 staff sourced from agencies/contractors. An issue with agency staff is the regular turnover of personnel.
  • The Board is particularly concerned that both secondary mental healthcare nurses have left post, one in the autumn of 2018 and the second at the start of 2019.
  • Healthcare applications to the IMB increased to 19 from 16 when compared to the previous reporting year.

Full IMB Report – HMP Huntercombe

IMB Report – HMP Whitemoor

Reporting period – 01 Jun 2018 to 31 May 2019.

  • One of the wings is a unit that accommodates up to 70 prisoners diagnosed with a personality disorder, and undergoing psychological treatment.
  • Prisoner on prisoner assaults were 51 per 1000 prisoners versus 296 nationally in male prisons; prisoner on staff assaults were closer to the average at 113 per 1000 prisoners, compared to 122 per 1000 nationally.
  • Self-harm incidents on main residential wings reduced dramatically from 129 to 28, and 148 ACCTs were opened, a reduction from last year’s 196. As last year, healthcare professionals, and psychologists were frequently absent from ACCT reviews.
  • Pressures on the healthcare service are noted owing to staff shortages, not least due to difficulties in recruitment which are exacerbated by the time it takes to process the background checks required for a high security prison.
  • The Board’s observations and prisoner feedback indicates that routine healthcare services are delivered effectively. Some improvements have been made during the reporting year such as the introduction of a visiting MRI scanner and the consolidation of healthcare champions.
  • For much of the year, there has been no evident leadership, with the deputy head of healthcare left to cope with an understaffed unit leading to inconsistent quality of care. Responses to complaints have been too slow. The contractual deadline is 28 days, but until late in the reporting year, this was not achieved.
  • GP services were a source of multiple complaints to the IMB, who could not assess prisoners’ disagreement with clinical judgements.
  • Major concerns remained about mental health provision who, as a team have been consistently understaffed and unable to deal effectively with the 25–45 mental health referrals per month made by the medical staff.
  • Referrals for transfer to secure mental hospitals have proved to be difficult. The time taken both for assessment, and, once accepted, for relocation remains excessive, leaving the local staff and facilities to cope with men whose challenging needs they are not trained or equipped to meet. The visible deterioration in prisoners waiting for a long time for a transfer are often observed by the Board.
  • Waiting times for services are broadly comparable with those in the general community, although there were longer delays for the optician and podiatry. No alternative arrangements were made for routine appointments during a period of 3 weeks when the dental surgery was being refurbished. Ophthalmology waiting time has been between 6 to 9 months. Whilst improving, the delay is still substantial.
  • The introduction of IEP warnings for missed appointments due to prisoner behaviour resulted in some improvement, but missed appointments are still running at about 220 per month. 15% are due to GP availability and 25% to the prisoner being unavailable for valid operational reasons. The cause of the remaining 60%, over 100 per month, is unclear. Nurse-led clinics form a significant portion of the healthcare provision and these are well attended and valued by the prisoners.
  • The appointment of healthcare champions on wings has advanced with the objective of securing consistent feedback on the provision of healthcare. Monthly meetings are often cancelled with less than 50% of those scheduled occurring.
  • Healthcare applications to the IMB increased marginally to 36 from 35 when compared to the previous reporting year.

Full IMB Report – HMP Whitemoor

IMB Report – HMP Belmarsh

Reporting period – 01 Jul 2018 to 30 Jun 2019.

  • There were 3 deaths in custody during the reporting year, of which 2 were natural causes and 1 being self-inflicted.
  • There were 231 incidents of self-harm, which included 104 incidents due to cutting, 61 by suffocation, and 10 through ingestion.
  • The inpatient unit has a capacity of 33 patients, of which an average of 40% require a controlled unlock.
  • Transfers to Mental health facilities were reported to take up to 9 months.
  • Non-attendance at clinic appointments were a concern, with DNA rates as high as 60% noted as being “standard.” Healthcare staff attribute the main reason for non-attendance is a shortage of prison officers available to collect prisoners once they have attended their clinic. Patients taken to out-patients in the morning can remain there after they have been seen until lunch time when they are taken back to the houseblock: prisoners are therefore reluctant to attend if it means spending up to 3 hours waiting to be returned to their cell. An additional reason for non-attendance may be that prisoners attending appointments instead of work or education do not get paid.
  • In excess of 500 medications are dispensed every day. Dispensing medication on the houseblocks has been a cause of friction between nursing staff and officers on occasion during the year, whereby the problem seems to arise through inconsistent detailing of officers to unlock.
  • Healthcare applications to the IMB decreased to 29 from 89 when compared to the previous reporting year.

Full IMB Report – HMP Belmarsh

IMB Report – HMP Stocken

Reporting period – 01 May 2018 to 30 Apr 2019.

  • There were 381 recorded incidents of self-harm, with an average of 32 per month (with a range of 20–54). However, if the eight most prolific self- harmers ceased to self-harm, incidents would fall by over 45%.
  • Stocken was one of 10 prisons chosen to pilot a new ACCT document. The new document (version 6) seems to be more coherent and informative, though initially more complex to navigate. This has been confirmed in conversations with officers and mental health staff, who both find it a distinct improvement. The number of ACCTs open at each month’s end was typically 16, with no discernible trend over the year.
  • There were 3 deaths in custody, of which 2 occurred on the same night on different wings (6 October 2018). The third was 3 months later.
  • Healthcare provision at Stocken has improved during the course of the reporting period. There have at times been serious shortages of staff, especially in mental health, and a necessary reliance on agency staff to plug gaps, although by the end of the period the department was in a much better position to deliver appropriate care.
  • Non-GP care has been reasonably satisfactory, though both the IMB and HMIP criticised the 6 week wait for dental appointments. Earlier in the year, the waiting time for GP appointments was 3 weeks, though more urgent cases could be seen within 4–5 days, or immediately for the most urgent.
  • The twice daily roll reconciliations proved to be disruptive and was discontinued in December 2018. Patients who had finished appointments were sometimes trapped in healthcare for up to an hour, while men with appointments pending missed them altogether as all movements were suspended. An internal review in August 2018 found that in the preceding 4 weeks, there had been 269 appointments which prisoners were unable to keep, wasting professionals’ valuable time.
  • Healthcare was well resourced in carrying out the smoking cessation programme, which has been judged by the IMB as being remarkably successful.
  • Vandalism to the chairs in the waiting area has meant the withdrawal of most seating, and there are now discussions about what kind of vandal-proof seating can replace them.
  • The area where the Board has had the most concerns is mental health. By the end of the reporting period, staffing was at its allocated level, but constant difficulties in recruiting and retaining staff earlier in the year led to long waiting lists. Agency nurses are mostly long-term hires and continuity of care is not a significant issue. The appointment of a full-time psychologist has been of considerable benefit since her appointment. The recent establishment of a drop-in clinic proved to be both effective and popular, such that it requires 2 sessions a week.
  • There is agreement on the part of all agencies here that the numbers of men with serious mental health issues, and also severe personality disorders, have increased. The Board is concerned that many of these men find themselves segregated for long periods of time, and frequently suffer from the “revolving door” syndrome of returning to a wing before shortly returning to the SU. Very often, this goes hand in hand with an increase in self-harm statistics (8 men were responsible for nearly 50% of recorded incidents this year). When the prison psychiatrist has declared that such men should be moved to a secure facility, the shortage of places as well as the choosiness of the receiving institution has led to lengthy delays before severely ill men’s needs can be addressed.
  • Healthcare applications to the IMB indecreased to 36 from 33 when compared to the previous reporting year.

Full IMB Report – HMP Stocken

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