An Introduction to Prison Medicine

An Introduction to Prison Medicine

Dr Catherine GloverClinical Director, Hanham Secure Health

GP Partner, Hanham Health

How the role of a prison doctor has changed over the years and how the general practice model has started to

be introduced into the prison setting

Aims

1. Background and context of prison healthcare - How did we get here?

2. Demographic of patient population

3. Case examples

4. Questions

Common Questions

» What is it like working in prison as a GP?

» Have you ever been attacked?

» What are the patients actually like?

» Why on earth do you do it??

There isn’t any of this…

Introduction

» It is a place of residence (sentenced vs remand)

» No choice as to where and from whom people receive care

» Collective ‘duty’ of care (at the hands of the State)

» Multiple service providers (commissioning is complex)

» What about ‘equivalence’?

Change in Prison Population

An Ageing Population

Patient Group

» Substance and alcohol misuse

» Poly-pharmacy & Safer Prescribing

» Mental health, self-harm and suicidality

» Complex needs

» Social exclusion and health inequalities

Healthcare Delivery

» Primary care plus

» Nurse-led services

» Closed (for now) IT System - System One

» Psychiatry, substance misuse, dental, optometry, physiotherapy,

podiatry, audiology, ultrasound…

» The majority of secondary care is outside the prison

» Escorts and bed-watches

» Appointments

» Support from security staff

» Telemedicine is being rolled out imminently…

Healthcare in Secure Environments

» Important clinical area which continues to develop

» Fertile ground for learning: clinical, ethical, moral

» Health inclusion

» Public Health

» Every contact counts

» Benefit to wider society - Community Dividend

» Rationale for increasing community resources?

Guidance

» Drug Misuse and Dependence 2017 - the Orange Book

» NICE Guideline’s NG57- Physical Health of people in prison, NG66

Mental Health of adults in contact with criminal justice system…

» PSIs & PSOs

» RCGP Safer Prescribing in Prison - 2nd Edition

RCGP Resources

Equivalence

Equivalence in Practice

» It must be recognised that there are aspects of care provision within

secure settings that require a different approach or service model

than would otherwise be available in the wider community

» On occasion, the care provided in a secure settings may be at least

equivalent to that available in the wider community.

Clinical Records

» TPP’s System One – ‘closed’

» Health & Justice Information System

» Limited connection to the NHS Spine

» No direct connection to Police Custody records

Medico-legal Considerations

» Complaints – PHSO (Parliamentary and Health Service Ombudsman),

PPO (Prisons and Probation Ombudsman)

» Clinical Negligence

» Deaths - PPO, Coroners Inquests: witness of fact

» Other areas: corporate/gross negligence manslaughter?

DNAs

» Movement within the prison

» Prison clinic appointments

» Movement between prisons

» Handover/continuity

» Movement outside the prison

» Hospital appointments

Case Example – Fracture

» 06 November: ‘History: attended a hotel 15 call. Patient states he was in a fight yesterday and had injured his right hand. Examination: His right hand appear swollen and 2nd knuckle appears displaced. Plan: Will task GP regarding ? x-ray’.

» 09 November: ‘History: seen this patient today to review his right hand after a fight. Patients hand is visibly swollen on the edge of the hand by the little finger, very tender to touch, Capillary refill <3 seconds painful when asked to wriggle fingers but states he feels pain. Task sent to GP for x-ray and analgesia. Have advised patient to attend the hatch and obtain simple analgesia to assist with the pain and swelling’.

» 19 November: ‘XR Hand Rt: There is a spiral fracture of the proximal metaphysis of the fourth metacarpal with mild displacement. The patient was referred to A&E following this attendance’. Mr F returned with an appointment for fracture clinic on 21 November. This appointment had to be rearranged for security reasons.

» 21 November: Mr F was unable to be escorted to fracture clinic appointment owing to ‘lack of officers’. Fracture clinic appointment re-arranged for 27 November.

» 27 November: Mr F was seen by orthopaedic consultant who advised that surgery will now be required for open reduction and internal fixation of the fracture.

Case Discussion – Fracture

» Barrier to accessing the Emergency Department as the patient cannot

choose to take themselves

» Failure to prioritise clinically

» Delays can be as a result of security implications

» Delays can be as a result of alterations to the appointed follow-up by

the hospital

» Causation needs the expert opinion of a consultant orthopaedic

surgeon

Hand Injury Pathway

Drugs

» Drug-seeking behaviour

» Challenging consultations

» Illicit use and diversion of medication

» Safety and risk management

» 1st night prescribing

» Heal v harm

Case Example – Drug Seeking

» 23 November 2011: Mr H arrives in prison and states that he is on various medications including methadone, mirtazapine, olanzapine as well as gabapentin.

» 15 February 2012: Mr H is seen by a nurse and is requesting to be changed from gabapentin to pregabalin as the former is no longer helping. There is no mention of his DVT at this time as to the cause of his pain, only the jaw.

» 17 March 2012: Mr H sees a prison GP who changes the gabapentin to pregabalin.

» 14 June 2012: Mr H requests an increase in his methadone from 60mg to 65mg reporting that he has symptoms of withdrawal. It is documented that Mr JH admits using illicit tramadol.

» 9 August 2012: Failed medication check with respect to his in-possession pregabalin, mirtazapine and quetiapine. It is also recorded that ‘intel’ indicates that his medication was being sold on the wing.

» 14 November 2012: There is documentation of Mr H buying medication on the wing.

» 08 January 2013: Mr H sees a prison GP and states that there three reasons for his gabapentin prescription, including ‘old scar Lt wrist’, DVT, fixed mandible both sides’.

» 12 March 2013: There is consultation where Mr H is “demanding” pregabalin for symptoms associated with his past DVT and that he will be contacting his solicitor if he does not get prescribed.

» 19 March 2013: Mr H is recorded as being moved to the Segregation unit.

Case Discussion – Drug Seeking

» Minimal clinical evidence supporting their presenting condition

» Clinicians vary in their understanding and approach

» Community v Prison practice

» Wealth of Guidance

» Often more readily defendable on the basis that Claimants will

struggle to find an Expert to support their case

Deaths

» Foreseen v Unforeseen

» Suicide and self-harm / ACCT

» Clinical Review of Death in Custody

» Equivalence, Use of restraints

» Coroner’s Inquest

» Professional Witness, Medical Defence Organisations

Case Example – Death

» Mr C was at HMP Garth where he was diagnosed with severe anxiety and was discharged from the primary care mental health team’s service. Mr C was transferred to HMP Liverpool in March 2016.

» An ACCT (Assessment, Care in Custody and Teamwork) was opened on 23 September 2016, following an incident in which Mr C had barricaded himself in and set fire to his cell. On the Concern and Keep Safe form, Mr C was noted to be low in mood. Mr C was moved to Segregation.

» On 27 September, Mr C was assessed and reviewed as part of the ACCT process and was assessed as ‘low’. Mr C was noted to state during the ACCT Review that he set the fire to escape threats of violence he was experiencing on the wing. The ACCT was closed but he remained in the Segregation unit.

» On 04 October, Mr C flooded his cell. He reported feeling unhappy, suffering from bad mood swings and feelings of paranoia to his Offender Supervisor. The Offender Supervisor made a referral to the mental health team and indicated a self-harm/suicide risk on the referral document.

» The ACCT was re-opened on 11 October following an incident whereby Mr C cut his ear with a razor blade and reported feeling ‘stressed out’. The GP spoke to Mr C and noted that he had said that he had cut his ear ‘by accident’.

» Prison Officer Phillips said at the Inquest that Mr C repeatedly told officers that he was going to kill himself. Further concerns were raised by the prison cleaner who informed officers that Mr C had said he would be dead by 20.00 that evening. There was no reassessment of the Mr C’s risks.

» On 23 October, Mr C was found hanging in his cell that evening and pronounced dead.

Case Discussion – Death

» Complex cases as they often involve a number of Defendants and

lines of responsibility

» Communication and relationships can be challenging to demonstrate

as numerous records are involved

» There may be additional factors that are not fully accounted for

within either healthcare or prison records

» Drivers for suicide in prison is not always as a result of untreated

mental health issues

» Inquests often lack contribution from Experts

Conclusion

» There are many valuable and distinctive ethical aspects of prison

medicine

» Still very much an area of development and innovation

» Prison medicine requires specific expertise and a sound

understanding of the context of the care being provided

» However, this area still lacks investment in terms of research and

funding for various reasons e.g. Public opinion and political

perception

Question and Answer

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