Tuesday, 26 August 2014

Healthcare: Prison Sentence or Death Sentence?

Ask pretty much any prisoner in the UK prison system to name the most dysfunctional, least effective department in any nick and I’d be willing to bet that healthcare would probably come at the top of the list. Fairly or unfairly, there is a widely held perception that the standard of medical care inside prisons is extremely poor. Having had personal experience of four jails run by HM Prison Service (plus two others in transit), I’m going to offer readers an insight into just a few of the worst horror stories I’ve encountered.

Medical care behind bars
Virtually every prisoner in the system will have had some interaction with healthcare staff, even if only for five minutes during the initial induction process. Newly arrived at one nick, my healthcare assessment consisted of three questions: was I feeling suicidal (no). Was I taking any prescribed medication (yes – for migraines). Was I on the methadone programme (no). “Next!” And that was about it. 

Despite my being on prescribed medication, no fresh repeat order was placed as it should have been, so once what little I held in possession on my arrival was finished, I had a three-week wait for the new supply, which was only ordered – very grudgingly – after I made three applications. Of course, I was very lucky. Although they can be agonising, migraines don’t prove fatal, unlike diabetes, which afflicts a growing number of cons as the prison population grows older. 

I pretty much lost count of the problems that diabetics experienced inside the slammer. Insulin not ordered or not kept in proper conditions; special diets ignored; outside hospital and clinic appointments cancelled at the last minute. And as for specialist chiropody treatment for those with diabetes-related problems, the chance would be a fine thing.

According to its official website, the Ministry of Justice (MOJ) claims grandly that “Prisoners get the same healthcare and treatment as anyone outside of prison”. I beg to differ. The UK prison system isn’t equipped to deal with people suffering from serious or life-threatening conditions or illnesses. The MOJ will claim otherwise, of course, but take it from one who knows: it really can’t cope. It may be another story in the very few prisons that offer special units for inmates who require palliative care, but across the mainstream prison system the situation is pretty horrific.

UK's growing prison populations
It also needs to be remembered that Britain’s prison population is ageing. According to MOJ statistics, in the category of ‘older prisoner’ (defined as being aged 60 or over) the total number incarcerated as of 31 March had reached 3,577. That means that the actual number of older prisoners has almost doubled over the past ten years and now accounts for around five percent of the 85,700-strong prison population. Of those older prisoners, 102 of them are aged 80 or above, with five men older than 90.

Before I’m accused of special pleading on behalf of cons, I should point out that I’m only too well aware of the shortcomings on the NHS outside the prison gates. I have close family members who have waited two years or more to see specialists and my own mother’s medical conditions were misdiagnosed for years before it was confirmed that she suffered from multiple sclerosis (MS). The NHS is under-funded and under incredible strain. However, the National Offender Management Service (NOMS) is responsible for the contracting out of prison healthcare services and – in theory, at least – the Prison Service has a duty of care to those it holds in custody. It is also worth remembering that even if these inmates weren’t serving prisoners, their medical conditions would still require treatment by the NHS in the community.

Prisoners can’t call in at the local branch of Boots to pick up over-the-counter remedies for minor ailments, nor can they take advantage of local clinics or A&E departments. Everything, from a headache to a heart attack has to go through the prison healthcare system and this, in itself, causes an overload. 

Prison doctor
Anyone who has done time inside will be familiar with the long line of prisoners standing outside the wing healthcare office. They are sometimes referred to as the ‘walking dead’. They go up to the hatch, one con at a time, to collect whatever medication has been prescribed for them. Most will have to take their pills there and then under the supervision of the nurse to guard against bullying or the resale of “meds”.

Inmates are a truly captive audience, so when the system fails to deliver appropriate care, there is little that they can do other than try to survive or, as in the case of a friend of mine whose serious health conditions weren’t being managed because he was being refused the pain relief medication that specialists outside the prison had prescribed (on ‘security’ grounds), they can commit suicide.

I’ll give you another example of a young prisoner known to me personally. He was on the methadone programme to manage his addiction and he suffered from a range of other health problems, including being unstable on his feet at times. One night, he climbed out of his top bunk to use the toilet and slipped. He fell and landed over the back of a metal-framed chair, crushing his testicles. Although he was screaming in agony, and his cell-mate pressed the call bell to get staff assistance, the night screw (‘the clocky’) just told him to get back into bed and shut up.

The next day he was in a very bad way and was unable to walk. Delays in getting an appointment with healthcare meant a three-day wait before he was seen by a nurse, then it took almost a further week until he was taken, handcuffed, to the local hospital. Of course, by then it was far too late and his condition was so serious that he had to be castrated. Yes, you read that correctly. 

When he was finally returned to the prison, after surgery, the powerful painkillers he had been prescribed at the hospital were confiscated and he was given paracetamol instead. News about what had happened went round among the staff and a couple of the screws he encountered found his predicament extremely funny. Just try to put yourself in his position – or imagine that this youngster was your own son.

The same treatment as anyone else?
After this life-changing incident, this young lad received no psychological support or counselling, nor did anyone discuss the possibilities of taking testosterone replacement with him. There was no option to have prosthetic implants. When I encountered him he was in deep depression and constantly thinking of suicide. I know his situation well because I volunteered to take up his case and we tried to initiate legal action against both the healthcare department and the prison authorities.

I’ve witnessed other horrific incidents. A lad broke his leg playing football and even though it was a complex fracture and the bones were visibly breaking through the skin, was told by healthcare staff that it was “just a bad sprain”. Fortunately, the gym screw – who I suspect had more humanity in him than the whole of the healthcare team – had been an Army paramedic and he told them what he thought of their triage diagnosis in no uncertain terms before contacting the duty governor and getting an ambulance called to take the bloke to hospital for appropriate treatment. 

Or the con who had such a serious tooth abscess that he was unable to eat, but couldn’t get any kind of dental appointment for weeks. Instead he was prescribed painkillers. Due to a ‘clerical’ error, however, he was in fact given massively strong doses of antipsychotics that were intended for another con who suffered from violent delusions. Because the two men looked vaguely similar, the duty nurse didn’t check their ID cards – as she was supposed to – before dispensing the tablets. Since they were given their medication in small plastic cups and were required to swallow them immediately, neither inmate suspected anything was amiss. 

Medical care in prison
It was only when the guy with a toothache ended up wandering round in a heavily sedated state that anyone realised there had been a massive cock-up. Naturally, the whole incident was hushed up and the lad with dental problems was quickly shipped out to another prison before he could cause any trouble. 

Despite this catalogue of horrors, and I could add many, many more specific incidents, it would be unfair to blame healthcare departments for everything. The environment in which they operate is not conducive to good doctor-patient relations and I’ve also witnessed some horrific behaviour by prisoners towards medical staff.

I have encountered a few excellent clinical staff and doctors in prison healthcare teams. These are the individuals who genuinely treated cons as patients and behaved with tact and humanity. Unfortunately, they stand out in my mind now because they were fairly few and far between. At least in the D-cat (open) prison I was at for nearly a year, the healthcare department was pretty good. In any case, a lot of cons who felt that they needed over-the-counter medication just popped into the local chemist when they were allowed out on home or day leave (ROTL), even though this was officially against the prison rules. 

On the 'dog lead' in hospital
One of the major problems faced by healthcare departments is trying to coordinate outside medical appointments with prison security. Most prisoners requiring any kind of medical or dental treatment outside the walls have to be escorted by officers, to whom they will remain handcuffed throughout their treatment, no matter how intimate the examinations or procedures may be. If prisoners need to be kept in hospital overnight (very few prisons now have facilities for in-patient care on site), then they can expect to be handcuffed to an officer via a long chain (known to cons as the ‘dog lead’). 

Therefore, if there is a shortage of security staff available to serve as hospital escorts, the appointment – which may have taken weeks or months to arrange – gets cancelled with little or no notice. It would be interesting to know the amount of taxpayers’ money that is wasted every year on cancelled medical appointments for prisoners and the true cost of the NHS resources involved when inmates aren’t produced for treatment. Perhaps an MP might like to ask that question in Parliament, because I’m certain that this situation is likely to get much worse owing to the current shortage of prison staff. 

I fear that given the escalating crisis in our prisons there will be a rising number of incidents where urgent – possibly life-saving – hospital treatment will inevitably come second to ‘operational issues’ (ie staff shortages) and some prisoners will probably die as a result. It’s in cases like these that a prison term can actually prove to be death sentence in the UK.


  1. Whilst I agree that the conditions in prison aren't good by any stretch (no pun intended), you should be aware that in the South East a typical GP has between 2,500 - 4,000 patients (and some in London are closer to 9,000) whilst I believe that the largest prison in England holds around 1,600 inmates, meaning that 'theoretically' there is typically a better ratio inside than outside.

    Of course, as your article says, I can go to Boots and buy some minor medication myself whilst inmates obviously can't but it's not all that great out here, from a health point of view.

    Finally, my wife was misdiagnosed for over 6 months by our GP whilst she developed Type 1 diabetes so levels of care obviously can be poor out here as well. Sadly there are many many instances of people waiting months/years for operations; the whole NHS system is overburdened and prisoners (from the sound of your article) are suffering just as many out here suffer.

    1. Thanks for your comment. I think that the actual prison ratio may not be quite so good since many prisons these days don't have a full-time doctor, but only have a contract that means a visiting GP holds surgeries a couple of times a week. That's when repeat prescriptions get signed off - if the duty nurse remembers, which sometimes they don't!

      I think the main difference between inside and outside is the additional variables in prison. Staff shortages mean that many appointments do get cancelled. Even in an open prison, this happened numerous times each week. Some were relatively minor issues, but I worked as a peer mentor with Macmillan cancer care and plenty of the people we supported through their cancer treatment found that their specialist appointments got cancelled, sometimes repeatedly. I'm not sure to what extent such cancellations happen outside prison, but there's no doubt the additional security dimension does have a major impact, particularly during the current crisis in UK prisons.

      Another key issue - as I mention in the post - is the withholding of strong painkillers. I came across this problem again and again. Even if external specialists had prescribed opiate-based medication for pain relief, this was very often confiscated by security on return to prison and healthcare then refused to re-issue or re-order, preferring for reasons of 'policy' only to provide ibruprofen or paracetamol. This, I'm sure, doesn't happen in the community. However, I do take your point about the general state of the NHS.

  2. I generally agree but I suspect that serious painkillers are more likely to be 'abused' in prison than in the community.

    1. That's certainly the reason given for withholding prescribed opiate-based medication. However, if the Ministry of Justice claim - quoted above - that prisoners receive the same medical care and treatment as everybody else is to be believed, then surely such decisions should be made on the basis of clinical need as determined by a qualified specialist, not by the prison security department. In any case, such medication is usually taken under supervision of the duty nurse, not held in possession by the inmate in his or her cell.

  3. Healthcare in prisons is a real issue.

    It's almost impossible to get an appointment with a GP in prison. My experience was to have to undergo a triage appointment with a nurse (maybe a week to arrange) who would then, if you were lucky, arrange an appointment with a GP within the next 3 - 4 weeks or so. I suppose that's fine for a long term non-essential visit but if you're in pain and need help fast you would probably recover from whatever it was before you managed to see a doctor. Anything life-threatening and you probably wouldn't have the time to see the GP at all!

    I won't add to the horrific stories of neglect that are already posted above, they don't surprise me. I could add other stories but I think the picture has already been painted very well.

    I was lucky not to have any serious health issues during my time inside. On reception I was prescribed a 7 day course of medication. I was given the pills for 2 days, on the third I was told I was "not on the list" despite my protests and so didn't receive any medication . Eventually on the 7th day, after daily complaints, I was called to get my "meds" by a screw. Luckily for me it wasn't a life threatening condition!

    I was lucky with illness - not even a cold, thankfully. In the B-Cat local I was in paracetamol had to be bought from the prison canteen. It was cheap to buy but the canteen ordering system could take up to 10 days for it to arrive - assuming you had the funds to buy it. If you need a couple of pain killers today - you need them - waiting 10 days isn't what you want. With foresight I always had a bottle of paracetamol pills in my pad - I took very few of them myself, but it was my fellow inmates begging them off me who got through most because they either couldn't afford the few pence they cost or just didn't foresee needing them a week in advance.

    I have to agree that the NHS in general isn't perfect. Healthcare in prisons is dire. You can't go to a drop-in GP, there's no A&E to attend, you can't pop into Boots and you really, really have to beg for an ambulance if you're seriously ill/injured.

    1. Thanks for sharing your experiences with readers. It is clear that healthcare in prisons is pretty dire, but that inmates face an even higher degree of exclusion than citizens outside in the community. As you will be only too well aware from your own experience inside, there is a tendency on the part of some wing staff to treat all illness as 'malingering' and to force prisoners - sometimes literally - to beg to be taken to healthcare.

      While ambulance delays on the outside do lead to tragedies all the time, when you add on the often very lengthy delays added on by the need to get healthcare to assess the emergency, then obtain authorisation to call and admit an ambulance into a prison, then to mobilise security staff as escorts, the additional delays can prove fatal. I'm sure anyone who has been in prison for any length of time can confirm this, most of us will have individual experience of knowing someone who has died. I can personally name six.

      On another issue you raise in your comment, it always amazed me that prisoners in some prisons could buy paracetamol on the canteen sheets. Even if there was a limit of one or two packets a week, a determined potential suicide could easily ask mates to purchase a pack each and stockpile the tablets until they have enough to take an overdose. It's an horrific way to go (a friend of mine at university did it and it's agonising, particularly as you appear to recover before your liver fails).

  4. Thank you for another very interesting post.

    Are there any figures for deaths in custody from "natural causes" that could have been prevented?

    As well as the poor standard of care, I have been appalled by stories of the ridiculous waste of limited resources through lack of common sense and local decision-making.

    e.g. when prisoners are taken to hospital, they have to go in a prison van, even if the hospital is literally across the road from the prison. (You probably know which prison I mean.)

    I also heard of an elderly man with heart problems who was rushed to hospital, and kept there for several nights chained to an officer. Clearly he was too much of a risk to be left alone. After he recovered, he was taken back to prison, and as his scheduled release date was the following week, he was then considered safe enough to roam the streets unsupervised.

    The whole area of risk management seems to have lost its way if stories like this one are compared with the recent example of an armed robber serving multiple life sentences who absconds from a D cat prison to do another robbery. Maybe that's another topic for a future post.

    Nevertheless, I do have some sympathy with staff who know how badly they will be hammered by the Daily Mail if they do anything that could lead to "prisoner escapes from hospital" headlines.

    1. To be honest I think that mismanagement and ridiculous practices probably contribute more to prisoners unnecessary suffering than any deliberate decisions.

    2. Thanks to you both for your contributions. I don't have any specific figures about "natural cause" deaths - as opposed to suicides, but I think they would be very instructive. Of course, people suffering from terminal conditions would - by definition - die as a result of these illnesses anyway, but the key question is whether their deaths have been hastened by the poor state of prison healthcare and bumbling bureaucracy. My fear is that delays in getting prisoners from hospital to emergency rooms will only get worse owing to current staff shortages.

      It's clear that all prisons are extremely risk adverse because of negative media attention concerning escapes and absconds. I suppose that a prisoner who did a runner from a hospital counts as an abscond as they would technically be on escorted ROTL outside the prison walls. In B-cats I've seen very elderly, disabled men chained up on their way to hospital appointments even though they probably couldn't walk 10 metres unaided, let alone escape!

      One issue I didn't mention in the blog post was the fact that some prisoners have undoubtedly had their lives saved by wing staff (often ex-forces) who administered CPR in cells during emergencies. I can think of two specific cases, but doubtless there are many more. Had these men collapsed alone at home, I imagine that they would have died on the floor, so it would be wrong to criticise all frontline staff - it's actually the delays caused by prison bureaucracy and current staff shortages that kill people, rather than individual acts of negligence or cruelty.

  5. Ah prison healthcare! On a good day its ragingly incompetent. On a bad day it will kill you. It's appalling how prisons are allowed to hire healthcare staff who should have been struck off for incompetence and that there is no real recourse for prisoners who have healthcare issues.

    1. Thanks for your comments. As noted in the post above, I've also come across some incredible examples of professional malpractice and incompetence by prison healthcare staff - ranging from a serious complex fracture being put down as a 'bad sprain' to the wrong prisoner being handed antipsychotics for a jaw infection, while the inmate with schizophrenia received painkillers, instead of his prescribed medication. If the potential consequences weren't so serious you'd imagine it was out of a Carry on Doctor comedy.

      Prisons administrations routinely cover for serious healthcare cock-ups. No-one saw anything or wrote anything down. I was once present during a 'code blue' when a fellow con stopped breathing because he'd had a major allergic reaction to a wrongly prescribed drug despite his medical records flagging this up. He nearly died and probably would have had several of us not had Heartstart CPR qualifications, since the screws took so long to raise the alarm and get a nurse to the room. Later, of course, everyone denied any knowledge of the incident and healthcare denied that he'd been given the wrong medication.

  6. Virtually every prisoner in the system will have had some interaction with healthcare staff, even if only for five minutes during the initial induction process.

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  7. PhDs appointed to the project. One, based at UCD, will work on prison reform movements; the other, based at Warwick, will investigate the health of women prisoners.