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The meeting was opened by the president, Dr Ian Munro. He expressed his conviction that Physicians for Human Rights (UK) should be concerned with allegations of human rights abuse within the UK as much as those from abroad and referred to the report of the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment which criticised medical care in the five English prisons they inspected in 1990. Quoting leaders from both the BMJ and Lancet he acknowledged that many people literally work themselves to death trying to make the prison system work but added that the prison doctor, however humane and dedicated, is involved in a situation of squalor, overcrowding and barbarity that he can do little to palliate and which he is forbidden by Home office secrecy to expose. In concluding he hoped that the recent surge in the debate over the future of the prison medical service might lead to significant improvements.
Dr Richard Smith is the editor of the British Medical Journal and has been described as Britain's foremost medical commentator on prison medicine. During his introductory remarks from the chair he described state of medicine in our prisons as a blot on British medicine. Ten years ago he had concluded that the prison service was in crisis and yet despite Strangeways, he observed, it staggers on.
There were 5 speakers who gave their presenation in the following order
Adam Sampson - Crisis in the Prison Medical Service
Alison Liebling - Suicide in Prison
Dr Anthony Maden - Psychiatric Disorders in Prison
Dr Sonya Leff - Mothers and babies in prison
Dr Vin Chiang - Doctors in Prison - a contemporary account.
Crisis in the Prison Medical Service
Speaker Adam Sampson has been deputy director of the Prison Reform Trust for three years. Prior to that he was a probation officer in Tottenham and before that a Junior Dean at Brasenose College, Oxford.
In crisis is also the term Adam Sampson uses to describe how he sees the prison medical service. As first speaker he presented a largely critical overview of the provision of medical services. One third of the 2500 complaints he receives annually about prisons relate to medical care although not all are subsequently substantiated. A succession of reports of unquestionable authority have, over the last 6 years, testified to the inadequacy of medical services:
Sources of reports critical of the Prison Medical Service over the last six years
• Royal College of Physicians
• Efficiency Scrutiny
• Social Services Committee of the House of Commons
• Almost all from the Chief Inspector of Prisons
• Repeated Inquest Verdicts
In common with all critics of the medical service in prisons, Adam Sampson recognises that doctors labour under grave difficulties. Their working conditions are poor with meagre resources and inadequate support services. Clearly doctors were not responsible for a woman’s baby being taken from her 6 hours after birth because there were no space in the mother and baby unit. They are not responsible for the appalling physical conditions in prison hospitals or for the understaffing and overcrowding that requires them to complete reception interviews on thirty prisoners in an hour.
They do not enjoy the same support service as their colleagues in the NHS - in 6 out of 7 cases nurses are prison officers who have undergone a short nurse training course. Prison psychiatrists, pharmacists and dentists are often retired or unsatisfactory in some way. And the number of complaints do, as prison doctors claim, to an extent reflect the high level of need of the prisoners. Prison is not a healthy environment with the restricted access to good food, exercise and fresh air. Despite their being mostly young men, prisoners are not, as a group, healthy people. Many have lived in poverty, abuse alcohol and drugs and have a psychiatric history, and they all live in stressful conditions.
Doctors argue that a lot of complaints are fabrications and that many prisoners are malingerers; yet the Gunn Report found many doctors excessively preoccupied with the problem of malingering. Adam Sampson suspects this erroneous perception to be even more prevalent among prison hospital officers who act as filters, restricting a prisoner’s access to doctors. In support he quoted information that came to light at an inquest 18 months ago. Brixton prison with its 1000 inmates, many of whom are psychiatrically ill, had not found it necessary to call out a doctor out once at night throughout a recent 5 year period.
Gunn also found a huge level of unmet psychiatric need. Of 114 with a neurotic disorder identified as requiring treatment only 18 were receiving it and fewer than a quarter of those who needed transfer to NHS facilities had been referred, let alone accepted. It is this that Adam Sampson sees as the crux of the problem with the medical service: that prisoners needs are not being identified - and when they are they are not being adequately treated.
There are crucial problems with the service, he went on. The best analysis of what is going wrong is the Efficiency Scrutiny set up at the instigation of Margaret Thatcher to bring the skills of the private sector to look at the state sector. That report, published in October 1990, identified problems which fell into two groups - problems with the staff and problems with the role of staff. Some medical staff were seen to be professionally isolated from their peers and some exhibited unnecessarily punitive attitudes.
Recruitment practices, terms and conditions and limited opportunities for career development mean that the service fails to attract and retain high calibre staff and there are few opportunities for prison doctors to keep up with developments in medicine. One result is that doctors were being required to undertake tasks, such as writing psychiatric reports, for which they were not qualified. Secondly, and Adam Sampson felt probably more importantly, there is a crucial tension between a doctor’s managerial role and his physician role. Prison doctors have to sit on management committees in the prison, they certify prisoners as fit for punishment and disciplinary proceedings and they have to write routine reports for the parole board. With the best will in the world, he suggested, it is difficult for doctors to separate their responsibility to patients as a doctor from the need to adapt medical care to meet the requirements of the current prison system. The previously high rate of psychotropic drug administration (the “liquid cosh”) and more recently the conniving over the segregation of HIV prisoners are two examples of the way that the competing obligations affect medical practice. The situation is so serious that Professor Tim Harding has argued that no prison doctor can keep to his Hippocratic Oath while working in the prison system.
The Efficiency Scrutiny report made 83 recommendations and all but one were accepted by the Home Office. The two most important were to employ NHS doctors on short term contracts to guarantee they do not get stale, develop bad habits or get isolated, and that an absolute distinction be made between a doctor’s clinical responsibilities and his management role. The response to that report has been inadequate, Adam Sampson maintained. In the intervening 2 years only one consultation paper, which dealt with a only one quarter of the recommendations, has been published. That paper contrives to misrepresent some of the recommendations, muddies the absolute distinction between a doctor’s current dual responsibilities and argues against getting rid of full time permanent doctors. Of the remaining three quarters of the recommendations - nothing has been heard.
In their defence, Adam Sampson concedes, it has to be said that the prison medical service is fighting in a part of the civil service which is notoriously slow moving, and there has been a change in name - to the Prison Health Service. But the reality is that, for the prisoners with whom he is in contact, nothing has changed. And nothing has been done to change his view that prison medicine has no proper future until it is integrated with the health services outside the prison system. He ended his address by asking the audience to heed the medical consultant to the Chief Inspector of Prisons who recently wrote “in all my years in the prison system I have still seen no sensible argument to convince me against the view that the prison medical service should be absorbed into the NHS.”
Suicide in PrisonSpeaker Alison Liebling is a Research Associate at the Institute of Criminology and a Research Fellow at Trinity Hall, Cambridge. She has worked in prison research for six years and has carried out two research projects on suicides in prisons. The first looked at suicide and suicide attempts in young sentenced offenders and took three years to complete. The second was expanded to include adults and male remand prisoners and was only completed the day before the conference.
The first project comprised a literature review followed by field work involving the collection of information on 50 people who attempted suicide and 50 controls -
Design the first project
• Thorough review of all the literature on suicide in prisons
• Interview and examine the notes of 50 prisoners who had made suicide attempts
• Interview and examine the notes of 50 prisoners chosen from the general prison population
The most important part of the interview was exploring every aspect of the inmates’ experience of prison and the most significant factor that came to light was that prisoners do not have a uniform experience of prison. Some find prison is very distressing and destructive - others cope quite well. Much research in this area has concentrated on seeking to answer the question ‘is prison harmful' ? What this piece of research demonstrates is that it is more harmful for some than for others.
The search for risk factors with which to identify potential suicide cases means looking in different areas. For instance it has recently been shown that the young male suicide rate in the community has gone up by 50% . Crucially most of that increase is confined to social classes IV and V from which the majority of the 16 -21 year olds who are in and out of prison originate. Thus those people most at risk of suicide in the community are the very ones that come into prison. It may not take much prison induced stress or many situational triggers to propel an already vulnerable person into a state of despair.
Some prisoners are not particularly vulnerable but are subject to so much stress and situational triggers - bullying can be a very serious factor with the young - that they go in the same direction. Thus suicide can be very difficult to predict. It is often not be possible to identify at prison reception the people in whom interactions between personality and the new situation is going to make them vulnerable.
There are very clear, usually very practical, usually non-medical factors which reduce suicide risk:
• Having visits from the family
• Having support from inmates, staff, or Samaritans
• Having counstructive work to do
• Having plans for the future
There is some dispute about the relative rates of suicide between community and prison. Although there has recently been a slow down in the rate of increase in suicides in prison, the suicide rate itself has increased since 1972 - dramatically since 1984. Comparison between the characteristics of suicides in the community and prison is difficult because those in prison are an at risk group. What can be said is that about 90% of community suicides have a history of psychiatric illness and that this contrasts strongly with those in prison where only 30% are found to have a psychiatric history. In the under 21 age group that figure drops to 13% - in other words the cause for 87% of those young male offenders committing suicide is more mundane, more focused on either their family situation or their prison situation.
Dr. Liebling’s task was to come up with a profile of people who might be at risk of suicide . This has been difficult to achieve - it is what most researchers have tried to do in the past. There is the danger that concentrating on trying to identify those at risk results in others being missed as often human behaviour is just not predictable in that way. One problem with the previous standard profile of suicide risk is that it was developed using information from deaths classified as suicide by coroners. One third of unnatural deaths in prison are given verdicts other than suicide. A psychiatrist, Dr Dooley, who examined their files concluded that a third of them, despite getting verdicts like accidental death, open verdicts or misadventure, were self inflicted. She also found significant difference between these deaths and those that get suicide verdicts - they were women, the young, people who die during the day and people who have injured themselves several times before .
Analysis of the interviews with the two groups of prisoners showed striking differences between them, although in most cases it was a question of degree rather than of an absolute difference - 5.
Historical factors distinguishing the suicide attempt group from the control group
• Many previous convictions
• short interval between convictions
• more likely to have received negative report from the probation service
• more likely to be at the receiving establishment as a result of a transfer taking them away from their family
• most were illiterate (limiting family contact)
• more likely to have truanted or been bullied at school
• more likely to have been in local authority home as a result of serious family problems (abuse, family breakdown)
• more likely to have had pyschiatric treatment and 50% have self injured
• more likely to have alcohol or drug problem
The behaviour of the suicide attempt group tended to excite an inappropriate response from the staff. An example is that their reluctance to take part in PE resulted in disciplinary reports rather than a recognition that some problem was preventing them from enjoying exercise in the same way that 95% of the control group did. Unfortunately it is often the inmates least likely to be able to cope with being locked up for prolonged periods, because they cannot read or write or have a destructive way of dealing with their problems, who were most likely to be confined. Again, this was often through their own actions - losing jobs, getting into fights or making themselves unpopular. But this whole pattern of behaviour demands a different response - it is crying out for some kind of constructive help from others. The second research project report ('Suicide Attempts in Male Prisons' by Alison Liebling and Helen Krarup, submitted to the Home Office in July 1992) which is not yet published, shows just how many of this group of prisoners end up in isolation.
Current factors distinguishing the suicide attempt group from the control group
• More likely to wish to share cell, either for help in reading/writing or for company than 50% tried to avoid PE (which exposes their vulnerabilities) vs. 90% of controls who keen on PE
• More likely to be inactive in cell therefore more bored
• Few friends in prison; often had serious problems with other inmates
• Being a disciplinary problem, exciting an unsympathetic response from staff, spending an inordinate amount of time in seclusion
• Little contact with the probation service
• Found thinking about the outside very difficult
Both studies demonstrate the medicalisation of prison suicide despite some effort on behalf of doctors to reverse it. One significant finding is that prison officers, despite knowing they can often deal with problems 'on the wing,’ always refer to the prison hospital when they recognise someone is getting depressed. They do not refer for advice, which might be an appropriate reaction, but rather for translocation of the prisoner to the ‘hospital’ where he is not treated but is actually secluded most of the time because there are no staffed wards. Doctors complained throughout the research that they feel totally constrained in their ability to treat because of the emphasis laid on the security requirements and the suicide risk that the person presents rather than the needs of the patient. The more depressed he is the more he is secluded - one of the most destructive things we have ever done in response to a suicide risk.
The second report also shows that what was found to be is true for the young offender - up to 21- in the first project is also the true for the under 26 year old group. Other types of prisoner that are especially at risk in slightly different ways are remand prisoners, sex offenders, short sentence prisoners, long sentence prisoners and lifers. Each group is affected by different factors and require separate analysis - for example short term prisoners are more likely to be affected by family and community ties which quickly break down, the young by activity variables, and so on.
Dr Liebling finished by emphasising that the differences between the two groups - the suicide attempt prisoners and the controls - was a question of degree, not of absolute difference. What the research demonstrates, she stressed, is a pattern. The recognition of this pattern contributes to our understanding of the development of suicidal feelings in prison and of how regimes may be improved to minimise them.
The second part of this report can be found on Medicine within prison part two
Post - script : ‘Strip’ Cells
In June 1992 Francis Cook, Director of The Howard League for Penal Reform, wrote to ask if the treatment of prisoners in this country was a matter of concern to Physicians for Human Rights (UK). An enclosed document, described as an excerpt from the 1991 Report of the Board of Visitors for Bristol Prison, expressed concern about the way suicidal prisoners are put into so-called ‘strip’ cells.
The use ‘stripped rooms’ is regularised in paragraph 33 of Circular Instruction 20/1989. They may be used, on the instructions of a doctor, to confine an inmate who is suicidal when a ‘protective room’ is not available, for short periods. A ‘protective room’ is a purpose designed room certified as providing a safe environment. A ‘strip’ cell on the other hand has been described as bare stark stone, often without decoration, with little or no natural light and containing only a mattress, a terylene blanket and perhaps a cardboard chair. The inmate strips completely to don a terylene shift and is allowed no possessions. They cells are often located in the punishment block and supervised by ordinary prison officers.
The Board of Visitors Report alleged that one prisoner had been isolated for 28 days without stimulation in a strip cell which was often very cold.
Clearly there is a risk that isolation in such an environment will have an anti-therapeutic effect on someone who is depressed.
• Dr Alison Liebling, in her talk, described the secluding of a suicidal person as one of the most destructive things we have ever done.
• The Gunn, Maden and Swinton report Mentally disordered prisoners describes the use of ‘strip’ cells thus - “The strangest part of the prison regime is its use of isolation for suicidal inmates. This has no place in the management of suicide cases in hospital and is contraindicated in the majority of cases. The suicide watch in prison, essentially a regular glance through the cell door to ensure the solitary inmate is not in the act of harming himself , is a grotesque parody of the close observation to be found in psychiatric hospitals.......In fact the the method is demonstrably unsuccessful in preventing suicide”
• Two Consultant Forensic Psychiatrist were asked for advice about the use for of ‘strip’ cells for potential suicide cases in prison. One suggested that isolation should be employed only where it would be indicated in hospital and the key to its use is very close monitoring and constant discussion about alternative management strategies. The other thought their use may be necessary but only for a few hours to allow for short periods of containment of very disturbed individuals whilst adequate assessment of their suitablity for transfer to an NHS facility is completed as soon as possible.
• The condition of ‘strip’ cells is mentioned in Mentally disordered prisoners - “....an acutely psychotic patient locked in a cell for a whole day. He may be clad only in a canvas shift with no possessions or furniture other than a mattress, possibly soaked in urine or soiled with faeces.”And by the the second advisor - “What is certain is that the disgusting condition in which many of these cells remain is unacceptable.”
The second part of this report can be found on - Medicine within prison part two - click