Patient safety in prisons: a multi-method analysis of reported incidents in England.

OBJECTIVES: Prisoners use healthcare services three times more frequently than the general population with poorer health outcomes. Their distinct healthcare needs often pose challenges to safe healthcare provision. This study aimed to characterise patient safety incidents reported in prisons to guide practice improvement and identify health policy priorities.Design: We carried out an exploratory multi-method analysis of anonymised safety incidents from prisons. SETTING: Safety incidents had been reported to the National Reporting and Learning System by prisons in England between April 2018 and March 2019. PARTICIPANTS: Reports were reviewed to identify any unintended or unexpected incident(s) which could have, or did, lead to harm for prisoners receiving healthcare. MAIN OUTCOME MEASURES: Free-text descriptions were examined to identify the type and nature of safety incidents, their outcomes and harm severity. Analysis was contextualised with subject experts through structured workshops to explain relationships between the most common incidents and contributory factors. RESULTS: Of 4112 reports, the most frequently observed incidents were medication-related (n = 1167, 33%), specifically whilst administering medications (n = 626, 54%). Next, were access-related (n = 559,15%), inclusive of delays in patients accessing healthcare professionals (n = 236, 42%) and managing medical appointments (n = 171, 31%). The workshops contextualised incidents involving contributing factors (n = 1529, 28%) into three key themes, namely healthcare access, continuity of care and the balance between prison and healthcare priorities. CONCLUSIONS: This study highlights the importance of improving medication safety and access to healthcare services for prisoners. We recommend staffing level reviews to ensure healthcare appointments are attended, and to review procedures for handling missed appointments, communication during patient transfers and medication prescribing.

Defining avoidable healthcare-associated harm in prisons: A mixed-method development study.

BACKGROUND: Reducing avoidable healthcare-associated harm is a global health priority. Progress in evaluating the burden and aetiology of avoidable harm in prisons is limited compared with other healthcare sectors. To address this gap, this study aimed to develop a definition of avoidable harm to facilitate future epidemiological studies in prisons. METHODS: Using a sequential mixed methods study design we first characterised and reached consensus on the types and avoidability of patient harm in prison healthcare involving analysis of 151 serious prison incidents reported to the Strategic Executive Information System (StEIS) followed by in-depth nominal group (NG) discussions with four former service users and four prison professionals. Findings of the NG discussions and StEIS analysis were then synthesised and discussed among the research team and study oversight groups to develop an operational definition of avoidable harm in prison healthcare which was subsequently tested and validated using prison patient safety incident report data derived from the National Reporting and Learning System (NRLS). RESULTS: Analysis of StEIS incident reports and NG discussions identified important factors influencing avoidable harm which reflected the unique prison setting, including health care delivery issues and constraints associated with the secure environment which limited access to care. These findings informed the development of a new working two-tier definition of avoidable harm using appropriate and timely intervention, which included an additional assessment of harm avoidability taking into the account the prison regime and environment. The definition was compatible with the NRLS incident report narratives and illustrated how the prison environment may influence identification of avoidable harm and judgements of avoidability. CONCLUSIONS: We have developed a working definition of avoidable harm in prison health care that enables consideration of caveats associated with prison environments and systems. Our definition enables future studies of the safety of prison healthcare to standardise outcome measurement.

Ethnic Minority Groups' Experiences of Suicide Bereavement: A Qualitative Exploratory Study.

It is estimated that between 36,000 and 360,000 people are affected by suicide every year in the UK, and a proportion may develop depression and post-traumatic stress disorder, or engage in high-risk behaviours. Recent systematic analyses have revealed a clear gap in research on suicide bereavement in minority ethnic groups. This study aimed to understand the experiences and support needs of individuals from ethnic minority backgrounds bereaved by suicide and was the first in the UK to investigate this matter. The study was a secondary analysis of data. Participants were 7158 people residing in the UK who completed an online survey about their experiences of suicide. Free-text qualitative responses of 227 participants who did not identify as White British were analysed using thematic analysis. Four themes were identified: maladaptive coping strategies, emotional processes following suicide, lack of support from agencies, and the importance of mental health awareness. Ethnic minority groups reported a lack of support despite attempts to engage with services, noted the prevalence of stigma within ethnic minority groups, and expressed a need to tackle this. These preliminary results suggest that ethnic minority individuals require visible and accessible services that can successfully engage with and support them.

Processes and challenges associated with establishing a linked national suicide database across the criminal justice system.

INTRODUCTION: There is a wealth of data contained within healthcare and criminal justice system (CJS) datasets that, if successfully linked, could provide more information about this population, particularly those offenders who die in non-custodial CJS settings where, comparatively, much less is known. OBJECTIVES: This study aims to determine feasibility of conducting data linkage across key criminal justice datasets and outline the processes, methodological considerations and any other implications of setting up such a linkage. METHOD: Five CJS datasets were identified for potential inclusion for linkage with Office for National Statistics (ONS) mortality data. Respective data teams were contacted, and scoping discussions were held via email, telephone contact and in person. Information was sought on available data, quality and completeness, unique identifiers, processes for record matching, cost implications, estimated timescales, required approvals, data security considerations and quality of data. RESULTS: All five datasets were deemed important to include and responses from data teams suggest that the proposed linkage is both feasible and valuable, within a reasonable timeframe and with minimal associated costs. The discovery of an additional 'spine' dataset provides a more effective method of record matching by linking police identifiers to unique prison and probation identifiers. CONCLUSIONS: The proposed linkage could highlight key points across the criminal justice system at which to target suicide prevention strategies. A more comprehensive linkage, including healthcare services, would further extend the opportunity to target interventions.

Experiences of support from primary care and perceived needs of parents bereaved by suicide: a qualitative study.

BACKGROUND: People bereaved by suicide are a vulnerable group, also at risk of dying by suicide. The importance of postvention support (intervention after suicide) has recently been highlighted; however, little is known about the support needs of parents bereaved by suicide in the UK, and the role played by general practice. AIM: To explore the perspectives, experiences, and support needs of parents bereaved by suicide. DESIGN AND SETTING: This was a qualitative study, with semi-structured interviews conducted between 2012 and 2014 in the north of England and the Midlands, with parents bereaved by their son or daughter's suicide. METHOD: Interviews explored parents' experiences of suicide bereavement following the death of their son or daughter, with a focus on their experiences of support from primary care. Interviews were analysed thematically using constant comparison. RESULTS: Twenty-three interviews were conducted. Three themes were identified from the data: the importance of not feeling alone; perceived barriers to accessing support; and the need for signposting for additional support. Some parents reported having experienced good support from their general practice; others described a number of barriers to accessing help, including triage processes. Primary care was considered to be an important avenue of support but GPs were often perceived as uncertain how to respond. The need for information, signposting to avenues of support, and the helpfulness of group support were also highlighted. CONCLUSION: Parents believed it was important that people working in general practice have an awareness of suicide bereavement and understanding of their needs, including knowledge of where to direct people for further support.

The mental health and substance misuse needs of male ex-armed forces personnel in prison.

Ex-armed forces personnel constitute the largest known occupational group in prison but there is little evidence regarding their mental health, or substance misuse, needs. A total of 105 participants were interviewed and measures assessing symptoms of common mental health (CMH) problems and substance misuse were completed along with a review of their health care records. Forty (38%) participants screened for current CMH problems (CCMH) and high levels of dual symptomology and alcohol misuse were assessed. Thirty-nine (37%) had a mental health diagnosis recorded, most commonly for post-traumatic stress disorder (PTSD), depression and personality disorder. Those who screened for a CCMH problem were more likely to have pre-service vulnerability to negative health outcomes and those with dual symptomology were more likely to have experienced deployment during their service. Findings suggest the mental health needs of this group are similar to the general prison population. Potentially higher prevalences of PTSD and alcohol misuse may direct service provision.

Treatment Barriers and Support for Male Ex-Armed Forces Personnel in Prison: Professional and Service User Perspectives.

Ex-armed forces personnel represent a potentially vulnerable group within the prison population. To provide support to this group, we need to understand their needs and help-seeking behavior. A focus group with professionals and semi-structured interviews with service users explored perspectives of the treatment barriers faced by this group and their support needs. Data were analyzed using constant comparison methods, and four primary themes were identified. The findings suggest ex-armed forces personnel consider prison an opportunity to access support but find it difficult to ask for help. Staff having an awareness of military issues was thought to encourage help-seeking, but the variability of provision across prison establishments was considered a barrier. Resettlement was a prominent concern, and access to support when preparing for, and after, release was felt by all participants to be important. Implications for the provision of support in prison are discussed along with recommendations for practice.

Soldier, civilian, criminal: identifying pathways to offending of ex-armed forces personnel in prison.

Little is known about why some ex-armed forces personnel become involved in the criminal justice system, however, they represent the largest known occupational group in prison. In-depth interviews were employed to explore possible pathways to offending. Twenty ex-armed forces personnel in prison were recruited from five prisons in England. Data were analysed using a combination of thematic analysis and constant comparison methods rooted in grounded theory. Four predominant themes were identified: experiences of trauma and adversity; belonging; impulsivity and creating a soldier. Participants had experienced a number of traumatic incidents and adversity in their lives, encompassing pre, during and post-service but felt a sense of belonging in the armed forces. Participants demonstrated impulsivity in a number of areas with links to both their service in the armed forces and offending behaviour. The creation of the identity of 'soldier' was perceived to impact participants' lives in a number of ways, including their offending, alcohol use and coping with trauma. The interplay of these themes and their potential impact on participants' pathways to offending are discussed.

Discharges to prison from medium secure psychiatric units in England and Wales.

BACKGROUND: Early findings from a national study of discharges from 32 National Health Service medium secure units revealed that nearly twice as many patients than expected were discharged back to prison. AIMS: To compare the characteristics of those discharged back to prison with those discharged to the community, and consider the implications for ongoing care and risk. METHOD: Prospective cohort follow-up design. All forensic patients discharged from 32 medium secure units across England and Wales over a 12-month period were identified. Those discharged to prison were compared with those who were discharged to the community. RESULTS: Nearly half of the individuals discharged to prison were diagnosed with a serious mental illness and over a third with schizophrenia. They were a higher risk, more likely to have a personality disorder, more symptomatic and less motivated than those discharged to the community. CONCLUSIONS: Findings suggest that alternative models of prison mental healthcare should be considered to reduce risks to the patient and the public.