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Dying on the Inside




For immediate release 2 April 2008

CROSS PARTY WELCOME FOR INQUEST’S NEW BOOK - DYING ON THE INSIDE: EXAMINING WOMEN’S DEATHS IN PRISON INQUEST’s new book Dying on the Inside: Examining Women’s Deaths in Prison was launched today in parliament at a meeting attended by cross-party MPs and peers.

The book is the first comprehensive examination of women’s deaths in prison in England & Wales between 1990 and 2007. It presents an alarming picture of preventable tragedy and the recommendations make fundamental proposals for change.

The key recommendation of the book is the abolition of prison as the normal response to women who break the law and investment in radical community-based alternatives.

For the first time the book brings into the discussion the largely unheard voices of bereaved families, some of whom attended and spoke at the launch.

Chaired by Baroness Vivien Stern, Senior Research Fellow at the International Centre for Prison Studies, the launch heard from the book’s authors Marissa Sandler and Deborah Coles, co-director of INQUEST. Also speaking were Julie Morgan MP, member of the House of Commons Justice Committee; Jenny Willott MP, Liberal Democrat spokesperson on prisons; and Kirsty Blanksby, twin sister of Petra Blanksby, a 19 year old woman who died in HMP & YOI New Hall in 2003.

Baroness Stern said:

“I congratulate INQUEST on this exemplary publication. We don’t need any more books, any more meetings about what is going wrong…we don’t need any more recommendations; we need action.”

Julie Morgan, MP for Cardiff North and member of the Justice Committee, said:

“These are all preventable deaths - that is the saddest point that can be made. I am committed to ensure that this issue is kept on the government’s agenda.”

Jenny Willott, Liberal Democrat MP for Cardiff Central, said:

“Prisons are effectively a dumping ground for people who are ill. This is not a party political issue, it’s a human rights issue. Anyone with an ounce of common sense can see it needs changing. It isn’t working.”

Kirsty Blanksby said:

“My sister died because she was a mentally ill woman who was wrongly sent to prison. I went through the same experiences as she did, but people believed in me – I went to the right place, a therapeutic community, which is why I am here to day, and she is dead.”

Deborah Coles said:

“It is shameful that the same issues of concern apparent in the 1990s are as prevalent today. This report provides incontrovertible evidence of serious human rights abuses of women in prison and the abject failure of the criminal justice system in dealing with women in trouble with the law. The research is so conclusive that the solutions are self-evident.

We don't need any more reviews or reviews of reviews. We need the abolition of prison as the normal response for women who break the law and investment in radical, community-based alternatives must be prioritised. The complex reasons behind why women enter the criminal justice system – homelessness, poverty, addictions, mental and physical ill health and sexual and physical abuse – must be addressed as a matter of priority. Without the political will to drive forward coherent policy change the female custodial population will continue to rise and more women will die.”

Inquests into the deaths of four women in prison open on Monday 7 April 2008.

• Vicky Robinson, aged 26, died on 2 February 2005 in HMP New Hall. The inquest will be held at Wakefield Coroner’s Court, 71 Northgate, Wakefield WF1 3BS, sitting before HM Coroner for West Yorkshire (Eastern District), David Hinchliff, and is expected to last three weeks.

• Sheena Kotecha, aged 22, died on 3 April 2004 in HMP Brockhill. The inquest will be held at Worcester Coroners Court, Bewdley Road, Stourport, Worcester, DY13 8XE sitting before HM Coroner for Worcestershire, Geraint Williams, and is expected to last two weeks.

• Lisa Woodhall, aged 28, died on 8 October 2006 in HMP Eastwood Park. The inquest will be held at Kings Weston House, Kings Weston Lane, Bristol BS11 0UR sitting before HM Deputy Coroner for the District of Avon, R, B, H Whitehouse and is expected to last one week.

• Lyndsey Wright, aged 30, died on 8 March 2005 in HMP Holloway. The inquest will be held at City of London Coroner's Court, Walbrook Wharf, 78-83 Upper Thames Street, London, EC4R 3TD sitting before HM Coroner Paul Matthews and is expected to last four weeks.

INQUEST is the only non-governmental organisation in England and Wales that provides an in-depth casework service to the families of those who die in custody. It undertakes policy, research and consultancy work on the strategic issues raised by contentious deaths their investigation, the treatment of bereaved people and state accountability.

Deborah Coles, Co-Director,

Deborah Coles, Co-Director,


89-93 Fonthill Road, London N4 3J

Phone: 020 7263 1111

Fax: 020 7561 0799

[email protected]

Healing effect

Inmates have a right to good healthcare, says the founder of a prison-based social enterprise. Involving ex-offenders, fining mental health trusts and rewarding GPs could be the answer, he tells Mark Gould

  • Interview by Mark Gould
  • The Guardian,
  • Wednesday February 27 2008

Peter Mason: "Prisons aren't great for your health." Photograph: Graeme Robertson

It was on a late-night bus home from a shift at Rikers Island, the then notorious New York super-penitentiary, that Peter Mason realised prison healthcare was the job for him. "The bus was usually full of black and Hispanic women and children coming home from visiting," he recalls. "But there were also these two black guys in hoods. They asked if I was a correction officer? I said, 'No, I'm a nurse,' and one said to the other, 'He's cool'. I realised then that the organisation I was working for was there for the prisoners. We didn't take pubic hair clippings from convicts to use as forensic evidence, we aren't part of the correction system - we are just there to do what we are trained to do, without prejudice."

Mason is the founder and chief executive of Secure Health Care (SHC), an old-fashioned industrial and provident society that ploughs earnings back into the service, and has some new ideas about tackling the horrendous state of health in UK prisons.

Mason talks of employing offenders within the prison healthcare system, fining mental health trusts that keep mentally ill prisoners inappropriately in prison, and paying a bounty to GPs to care for ex-offenders to cut overdose deaths following release. He feels that offender healthcare must develop as a specialism in itself, like elder care or community care, and wants to set up an SHC college to make it happen.

In July, SHC won the bid to provide NHS care for Wandsworth prison, south London, one of the largest in Europe.

The prison population harbours astounding levels of physical and mental illness. Two-thirds of the 82,000-plus prisoners have a mental illness, many with the complication of drug or alcohol addiction and/or a learning difficulty. HIV, tuberculosis and hepatitis are rife. These factors, plus overcrowding, were cited as part of the reason for a startling 37% increase in self-inflicted deaths among convicts, from 67 in 2006 to 92 last year. But it isn't just what happens inside prison that concerns Mason. When inmates leave prison, they fall off the radar of health services, he says. A shocking 160 ex-prisoners die each year due to drug overdose within 14 days of discharge.

Growing problem

Wandsworth is a vast Victorian recreation of a medieval castle, built in 1851. The wings radiate from a central hub so that prisoners can be observed without knowing they are being watched. It holds more than 1,400 men, but is due to be extended to hold 100 more.

Mason, a trained NHS psychiatric nurse and an academic who has worked and studied in US prisons, is emphatic about the growing problem of mental illness in prisons. "It's almost immoral that the [medical] profession should stand back and allow mentally ill patients to be caged in prisons at the rate they do," he says.

He complains about the problem of prisoners unable to be discharged because there are no suitable psychiatric beds.

His solution? Fining mental health trusts, just as local authorities are fined if an elderly patient is stuck in a hospital bed because there are no care home spaces. "I think fining them £300 a day to keep somebody in prison is a way to focus minds," he argues.

The government has just launched a cross-departmental consultation setting out its vision of the future of offender healthcare, both inside and outside the prison, and it almost looks as if Mason wrote the document. Mason's approach to improving services is via an organisation that puts profits back into the service and that is membership-led and employee-owned, where everyone - clinicians, prison officers and prisoners - is to varying degrees a member and can have a say in what it does.

SHC was introduced to Wandsworth via the prisoners' newsletter, The Landing, and Mason quickly set up a prisoner forum to ask the men what they felt about the quality of healthcare and how it could be improved. He introduced a prisoners' health charter, which spells out roles and responsibilities. "We promise that prisoners will get a level of care that is equivalent to that in the community, and that all care we provide is evidence-based," Mason says. "They have a right of confidentiality - we aren't prison officers - and they have a right to continuity of care when they leave. As part of the rights and responsibilities, prisoners are also informed that they should turn up for appointments, rather than going to the gym or saying they have something better to do."

The forum revealed that the prisoners, just like people on the outside, want faster access to appointments and a better attitude among staff. They feel that people never listen to them.

Some changes seem to be taking time for the prisoners to get used to, such as senior nurses providing more care. SHC has employed an advanced nurse practitioner as lead nurse, but Mason says prisoners still think they should be seeing a doctor. And it has introduced a foundation course for all staff giving them the principles of prison healthcare. Prisoners no longer turn out for "sick parade" or, if they are really unwell, report "special sick". "The vocabulary needed to change," Mason says. "It's all part of the normalisation process."

Just 13% of Wandsworth inmates come from south London, and Mason says he wants to set up a local contact centre so that men leaving prison can find out where to get a GP and where to find a 24-hour pharmacy. He also wants it to be available for people coming back to the area after leaving any prison in the UK. "People are so vulnerable during those first few weeks after leaving," he stresses.

SHC has introduced iris recognition methadone pumps to speed up dispensing. The prisoner looks into a retinal scanner, which identifies him, and then dispenses the required dose of heroin substitute. Other hi-tech plans include the introduction of tele-healthcare, linking the prison to consultants in local hospitals, cutting down on the need for expensive and time-consuming escorted trips. Digital x-rays will also speed up diagnosis, with images sent by computer to specialists for interpretation.

Mason also wants to develop more mental health services to tackle the stress, anxiety and depression generated by prison. "Prisons aren't great for your health," he says. "They aren't meant to be lovely places, so people need to know of ways of surviving."

Relative safety

What about personal safety? "Security and safety are of course important features," he says. "Prisons are relatively safe places for doctors and nurses because prison officers are so skilled at handling prisoners and diffusing difficult situations. But healthcare staff are the champions of prisoners - we are not the enemy."

He also sees nothing wrong with employing ex-offenders, subject to the selection procedures. "We have set up a health trainee course for prisoners to help them learn about fitness and how they can signpost other prisoners to care if they need it. A lot of prisoners show a very caring instinct and want to give something back. Some could become care assistants. It's an ideal opportunity. I don't see why ex-offenders couldn't become call handlers, drivers, porters or admin workers, and work in their own organisation."

Mason says it was pure serendipity that saw the creation of SHC. Primary care contracts had become more flexible and the NHS was being opened up to a wider range of providers, including the private sector and social enterprises. At the same time, the responsibility for prison health was handed over to the relevant local NHS primary care trust. SHC inherited 64 existing prison health workers under transfer, and has also brought in a lot of its own senior nursing, managerial and medical staff. It tries to recruit locally where possible. "We wanted to get local people involved because we are a local employer, and to open up the place and dispel some myths," he explains.

But SHC's status as a contractor means that it does not come under the protective wing of the NHS indemnity scheme. Mason is concerned that social enterprise companies such as this have to stump up their own clinical negligence insurance - and the premium for working with prisoners comes to £160,000 a year.

What about the problem of ensuring prisoners stay in touch with health services on discharge, particularly during that crucial period immediately after release when overdose is most likely? He feels that the NHS could follow an example from a programme at Rikers Island that paid a fee to substance misuse clinics that took on ex-prisoners. "GPs could be paid a bounty to ensure ex-prisoners aren't excluded when they are released."

Mason says he is happy with the direction of travel set out in the consultation on the future of offender care, but is clear about who shouldn't be involved. "I am opposed to private healthcare providers working in prisons," he says. "I don't think it's right that they should be making money out of incarcerated people."

Curriculum Vitae

Age: 49.

Status: Married.

Lives: London.

Education: Chalvedon comprehensive school, Essex; Leicester University, BSc health science studies; Maudsley hospital and Institute of Psychiatry, diploma in behavioural psychiatry; Bethlem and Maudsley School of Nursing, registered mental nurse; Barking and Havering chool of Nursing, state registered nurse.

Career: 2007 to present: chief executive, Secure Health Care; 2000-07 chief executive, Centre for Public Innovation; 1993-2000: director, PDM Consultancy; 1992-93: Harkness fellowship, Columbia University, US; 1989-92: regional development manager, substance misuse services, North West Thames Regional Health Authority; 1977-80: various nursing and nurse management posts in mental health.

Interests: Jogging, tending allotment, sailing, music.

Time to act on behalf of mentally disordered offenders

PERSONAL VIEW Becky Sales, Nigel McKenzie

Over the past six months the British media—general and medical—have increasingly focused on two apparently unlinked issues relating to offenders and the criminal justice system.

The first issue is the current overcrowding crisis in prisons, as the number of prisoners exceeds capacity (80 000 in England and Wales).

The second is the new Mental Health Bill and the debate surrounding it as it passes through parliament.

In terms of criminal justice this debate has largely centred on the balance to be struck between the human rights of mentally disordered offenders and protection of the public. What is striking is the focus on patients with potentially untreatable disorders (such as personality disorders) rather than any debate concerning—or even with reference to—the human rights of those with treatable disorders, such as those with acute psychosis.

Each year in England between 5% and 8% of all patients (or 1300 to 2000 patients) detained under section in psychiatric hospitals come through the court or prison systems. Unlike their counterparts in the community these patients will wait several months for a hospital bed and are invariably floridly psychotic and untreated. Why untreated?

Apart from those sections relating to transfer, the Mental Health Act of 1983 does not apply in prison.

Among the countries of Western Europe, England and Wales currently have the highest rate of incarceration per 100 000 people, although those countries are not alone in having a significant over-representation of people with a psychiatric disorder in the criminal justice system—variously estimated at between 60% and 90%. This problem is common to many countries, including most of Europe and the United States, as is the inability to ensure the rapid transfer of patients with acute mental illness out of prison and into hospital.

Prison healthcare policy in Europe, including the United Kingdom, is underpinned by the concept of equivalence of care with that of patients in the community. Equivalence of care should mean that those patients in prison who need to be admitted to hospital under the Mental Health Act wait no longer than those patients who are sectioned in the community. Equivalence of care—along with the right to health (article 12 of the United Nations’ International Covenant on Economic, Social and Cultural Rights) and the right not to be subject to torture or to inhuman or degrading treatment or punishment (article 3 of the European Convention of Human Rights, enshrined in UK law as the Human Rights Act 1998)—should form the basis of health care provided to mentally ill prisoners.

The reality is somewhat different.

So why are we failing?

The issues relate not only to culture and resources but also to the failure of the Mental Health Act and of health commissioners to provide adequately for these patients. Well known factors contributing to this failure include the lack of diversion of mentally disordered prisoners by the courts and the police; poor care in the community; and the pressure on beds in acute psychiatric intensive care units and in medium secure units.

Less recognised factors are the lack of “stepdown facilities” and of appropriate pathways of aftercare, with the consequent bed blocking in medium secure units. Emphasising the role of the patient’s commissioning primary care trust in ensuring timely transfer, without placing any statutory obligation on trusts, is unlikely to produce a satisfactory outcome in a time of NHS financial crisis.

The review of the Prison Mental Health Transfers Programme is due to present its findings later this year. Will it recommend major change to the whole process of transfer of prisoners under section—change that is backed by law and resources—rather than merely altering procedures?

We propose that the new Mental Health Bill be amended to incorporate a time limit for transfer to hospital from prison in the appropriate sections of the bill (sections 47 and 48). This time limit should reflect what would be considered appropriate in community psychiatric settings, thus fulfilling the concept of equivalence of care as well as basic human rights.

We also suggest that the bill should contain statutory obligations to ensure that those patients who are judged as needing hospital treatment while in police custody or in the court system cannot be sent to prison.

Of course, much wider debates may be had regarding the interplay between the criminal justice system and mental illness. The paradox of a prison population with a high number of prisoners awaiting hospital beds at a time of much demand for greater prison capacity is best exemplified by Ashworth, a closed psychiatric hospital wing that has now reopened as a prison (HM Prison Kennet).

What is unarguable, however, is that acutely psychotic patients should not be in prison.

Surely in the 21st century it is time for us as health professionals to act on behalf of one of the most forgotten, disempowered, and disadvantaged groups of patients?

Becky Sales is lead GP and Nigel McKenzie is consultant psychiatrist, HM Prison Pentonville, London

[email protected]

BMJ | 9 JUNE 2007 | Volume 334