Offenders with mental disorders in prison and the courts: links to rates of civil detentions and the number of psychiatric beds in England - longitudinal data from 1984 to 2016

Delays in transferring patients from prisons to secure psychiatric hospitals: An international systematic review

BACKGROUND

Transfer to a psychiatric hospital of prisoners who need inpatient treatment for a mental disorder is an important part of prison healthcare in the UK. It is an essential factor in ensuring the principle of equivalence in the treatment of prisoners. In England and Wales, delays in transferring unwell prisoners to hospital were identified by the 2009 Bradley Report. There has been no subsequent systematic review of progress in so doing nor a corresponding appraisal of transfer arrangements in other parts of the world.

AIM

To conduct a systematic review of international literature about transfers of mentally unwell individuals from prison to hospital for the treatment of mental disorder since 2009.

METHOD

Eight databases were searched for data-based publications using terms for prison and transfer to hospital from 1 January 2009 to 4 August 2022. Inclusion criteria limited transfer to arrangements for pre-trial and sentenced prisoners going to a health service hospital, excluding hospital orders made on the conclusion of criminal hearing.

RESULTS

In England, four articles were identified, all showing that transfer times remain considerably longer than the national targets of 14 days (range, 14 days to >9 months); one study from Scotland found shorter mean transfer times, but more patients had been transferred to psychiatric intensive care units than to secure forensic hospitals. There were only two studies that investigated prison to hospital transfers for mental disorder from outside the UK and only one reported time-to-transfer data.

CONCLUSIONS

Findings from this literature review highlight failures to resolve transfer delays in England and provide little evidence about the problem elsewhere. Given the lack of data, it is unclear whether other countries do not have this problem or simply that there has been no research interest in it. A possible confounding factor here is that, in some countries, all treatment for prisoners' mental disorders occurs in prison. However, the principle that prisons are not hospitals seems important when people need inpatient care. Prospective, longitudinal cohort studies are urgently needed to map transfer times and outcomes.

Highlighting "Risky Remands" Through Prisoner Death Investigations: People With Very Severe Mental Illness Transitioning From Police and Court Custody Into Prison on Remand

Prison suicide/self-inflicted death is an international public health crisis, harming stakeholders including bereaved families, prisoners, prison staff and death investigators. England and Wales' record prison suicide numbers in 2016 cost at least £400 million. Death rates are an indicator of prison safety, and unsafe prisons mean unsafe societies. I present four case studies of people with very severe mental illness who were remanded to prison from police and/or court custody and went on to take their own lives in prison. I use publicly available data from Ombudsman and Coronial death investigations in England and Wales, highlighting that these accessible sources could be more widely mobilized to reduce the substantial harms and costs of prisoner deaths. Case studies include three men (Lewis Francis, Jason Basalat and Dean Saunders) and one woman (Sarah Reed) who took their own lives between January 2016 and April 2017. All four people were clearly very mentally unwell at the time of their alleged offense and remand to prison. I develop the concept of "risky remands" to highlight that people with very severe mental illness being remanded to prison is a particularly problematic practice. I highlight the implications of people with very severe mental illness transitioning into prison in the first place, arguing that being remanded to prison is not an acceptable or safe pathway into healthcare. I illustrate that police custody suites and courts may lack awareness of mechanisms and/ or the practical ability to transfer ill detainees charged with a serious crime to mental health facilities for assessment and/ or treatment. My analysis amplifies and extends recent Criminal Justice Joint Inspection findings that it is unacceptable to use prisons as a "place of safety," and that the Department of Health and Social Care, NHS England and the Welsh Government must increase the supply of medium and high secure beds. Moreover, Ombudsman investigations did not engage with the remand transition, effectively legitimizing this risky practice for very ill people. As such, my analysis also counters the apparent "problem of implementation" in prison oversight, instead questioning what reviewers recommend, based on which evidence.

Space and Well-Being in High Security Environments

Research into the spatial dimensions of deprivation of liberty and psychiatric hospitalization has a long and complex tradition. In this context, the increasing numbers of prisoners and patients in forensic hospitals have impressively shown how difficult it is to ensure security, therapy and rehabilitation when space is scarce or not well-suited. In this narrative review, we present the main findings of recent lines of research on spaces in prisons and forensic psychiatric wards, with particular attention to the links between overcrowding in prisons and secure forensic psychiatric hospitals and violence, the foundations of prison and hospital architecture, and on how the design of spaces in prisons and hospitals can influence well-being. We assess and discuss these findings in the context of the current debate on how well-being in secure spaces can support the achievement of rehabilitation goals even in overcrowded institutions.

Expert Arguments for Trends of Psychiatric Bed Numbers: A Systematic Review of Qualitative Data

Introduction: Mental health policies have encouraged removals of psychiatric beds in many countries. It is under debate whether to continue those trends. We conducted a systematic review of expert arguments for trends of psychiatric bed numbers. Methods: We searched seven electronic databases and screened 15,479 papers to identify expert opinions, arguments and recommendations for trends of psychiatric bed numbers, published until December 2020. Data were synthesized using thematic analysis and classified into arguments to maintain or increase numbers and to reduce numbers. Results: One hundred six publications from 25 countries were included. The most common themes arguing for reductions of psychiatric bed numbers were inadequate use of inpatient care, better integration of care and better use of community care. Arguments to maintain or increase bed numbers included high demand of psychiatric beds, high occupancy rates, increasing admission rates, criminalization of mentally ill, lack of community care and inadequately short length of stay. Cost effectiveness and quality of care were used as arguments for increase or decrease. Conclusions: The expert arguments presented here may guide and focus future debate on the required psychiatric bed numbers. The recommendations may help policymakers to define targets for psychiatric bed numbers. Arguments need careful local evaluation, especially when supporting opposite directions of trends in different contexts.