Healthcare provision in prisons: continuity of care

We would like to thank the patients and healthcare and prison staff who engaged with the investigation for their openness and willingness to support improvements in this area of care.

This report is intended for healthcare and justice organisations, policymakers and the public to help improve patient safety in relation to continuity of care for patients detained in prison.

This section describes the investigation’s findings in relation to the continuity of care delivery within prisons. The findings are grouped within themes according to the key stages of patient care and continuity of care processes, as identified by the investigation’s analysis of the evidence. The themes are as follows:

• hospital waiting lists and clinical holds
• missed medical appointments
• prison escorts to outpatient appointments
• telemedicine.

The analysis and findings show a system that does not support an engaged healthcare system where patients are involved, informed and keen to attend appointments.

The decreasing rates of attendance for internal appointments, the lack of patients’ engagement in their own healthcare, and an easy acceptance of refusal to attend by patients and staff, led to non-attendance being normalised. Patients did not consider whether healthcare appointments were internal or external; it was a healthcare appointment that did not sit high in their priorities list.

The impact of this was felt through the entire prison healthcare system and continued to hospitals, where patients from prison not attending appointments increased hospital ‘did not attend’ (DNA) rates. Hospitals were trying to reduce DNA rates as their waiting lists increased, but efficiency was not helped by DNAs by patients from prisons that were out of hospitals’ control.

2.1.4 Staff working in appointment booking teams at NHS trusts that provide a service to prisons stated that there was a system for transferring patients around the country that accounted for the amount of time they had been on waiting lists. The system was based on the initial referral date as this was when the patient would have been placed on the waiting list, rather than on their position in the list. This approach ensured that they received a locally appropriate position on the list when they were transferred. One member of staff told the investigation that “nobody’s penalised from moving from one place to another”.

2.1.5 All hospitals used a form to send a patient’s details to their new treating hospital, ensuring that their position on the waiting list was not lost. The form was called an ‘inter-provider transfer’ form (see figure 1). While this practice was common knowledge within the hospital booking teams the investigation spoke with, it was not well known outside of them, particularly in the prison healthcare teams or among patients themselves.

Figure 1 Inter-provider transfer form

Hospital booking teams told the investigation that communication between themselves and prison healthcare departments was often an issue. There was often a delay in the hospital booking teams finding out that a patient had been moved to a different prison. This could cause a delay in care if they were near the top of the waiting list, or meant they could miss their appointment because of the transfer, causing delays in diagnosis and treatment. Hospitals had to either transfer the patient to their new hospital or discharge them once an appointment was missed.

2.1.6 In addition, the bookings teams did not have a forwarding address for the patient once they had been transferred, another factor which could cause delays in a patient’s care. The issue of communication between healthcare admin staff and acute trust booking teams is also covered in 2.2.22.

Clinical holds

2.1.7 Prison Service Order (PSO) 3050, ‘Continuity of healthcare for prisoners’, states:

‘Patients may sometimes need to be placed on ‘clinical hold’ (i.e. withheld from transfer for a period of time for clinical reasons when indicated). This system will require local audit through clinical governance arrangements to ensure that;

• Clinical risk is managed
• The operational running of the prison is not adversely affected by excessive numbers of clinical holds.

‘For instance, it will almost never be appropriate to transfer a patient awaiting urgent cancer referral. However, where prison population turnover is high, as in local prisons, it may only be possible to hold those patients with clinically urgent appointments. Training prisons may be able to hold more patients awaiting outpatient appointments.

‘Patients may sometimes be transferred after having waited a considerable time for hospital treatment. In these circumstances details of the wait should be included in the referral letter from the new establishment to determine whether this may be taken into account at the new hospital. Clinicians should attempt to reach agreement that the waiting time will not be reset when the patient is transferred to a new list. In exceptional circumstances, prisoners may need to be transferred for security reasons and these may take priority.’ (HM Prison and Probation Service, 2006)

2.1.8 The investigation observed during visits, and was told by staff, that individual prison stances on clinical hold varied. Many of the prison healthcare staff stated that they were not allowed to keep patients at the prison on a clinical hold, while others described a more collaborative system with the operational side of the prison, where they could keep the patients as long as they could justify it.

2.1.9 A common justification for a clinical hold was that a patient was waiting for a cancer diagnosis or was receiving treatment. However, staff from some prisons said that they had received patients who they ‘wouldn’t have transferred’ because they were undergoing or awaiting such treatment. The variation in standards for clinical hold had caused frustration within some healthcare departments, as they felt that were being held to a different set of rules.

2.1.10 Clinical holds were a particular concern for category B local prisons (see 1.3.5). Because of their high turnover of prisoners, they regularly had patients who the healthcare teams felt should be held while they waited for appointments, but they were under the most pressure, from the operational side of the prison, not to have clinical holds. Staff stated that the pressure on the prison system to make space for remand prisoners was affecting the ability of staff to make best treatment decisions.

2.1.11 The investigation was told that healthcare facilities differed between prisons and this affected their ability to provide the required level of care for some conditions. Therefore, the healthcare department within a prison might try to reject the transfer of a particular prisoner into their prison on the basis that they did not have the facilities necessary to manage their healthcare needs. One healthcare team told the investigation that they had on occasion been overruled (that is, a clinical hold at the transferring prison had been refused) by the operational side of the prison and a transfer into the prison had to take place. They explained that this caused challenges for the healthcare team as they had to provide a level of care they were not set up for.

HSSIB makes the following safety observation

2.2.3 As with patients in the community, in prisons there can be wait times of a couple of weeks for GP appointments. However, the investigation heard that in most cases the wait for GP appointments was shorter in prison than in the community. There was a lack of awareness among patients in prison that while the wait times were sometimes in line with the community, in many cases wait times were shorter in comparison.

2.2.4 The investigation found that there was wide variation in attendance rates for clinics depending on the nature of the clinic, and also large differences in attendance rates between the male and female populations. In data supplied by two of the male prisons visited, clinics that dealt with substance misuse or addiction were very well attended with rates above 90% and often at 100%. By contrast, monthly attendance rates for other clinics, such as podiatry, dropped as low as 27%, with an average attendance rate of approximately 64% across a 4-month period. The investigation was told by patients and healthcare staff that patient awareness and health education may be a factor in non-attendance at some clinics.

2.2.5 In female prisons attendance rates and general interaction with healthcare were significantly higher. In one of the female prisons visited, the overall attendance rate for all internal clinic appointments was 94% to 97% over a 6-month period, with every female prison telling the investigation that they had good engagement with and attendance from their patients.

2.2.6 National data, supplied to the investigation by NHS England, showed that across all prisons, attendance at internal clinic appointments was not as high as was indicated by the data provided by the prisons visited by the investigation. Across five different clinic types (GP, dental, mental health, nurse, and substance misuse), the national data shows a sharp increase in the number of patients not being seen after appointments had been booked. Figure 2 shows the rise in the number of patients not being seen.

Figure 2 Patient attendance at prison primary care appointments

2.2.7 While there was an increase in the total number of appointments being booked by healthcare departments from 2022 to 2024, the percentage of those appointments that resulted in a patient not being seen rose sharply from 16.7% in 2022 to 49.4% in 2024. The investigation was told that there were several reasons that contributed to patients not being seen, which included:

Patient refusal:

• prioritisation of visits, gym or social time with peers
• not wanting to potentially spend hours in an uncomfortable waiting area, with no facilities to occupy the patients (books, magazines, TV, radio).
• forgetting why they had the appointment
• dismissing the health concern
• the initial concern had gone, such as colds and sore throats- patients not being escorted to the healthcare department.

Patients not being escorted to the healthcare department:

• restricted to their cells due to operational reasons (such as, the prisoner count being wrong or an incident on the wings)
• taken to place of work
• appointment slips not delivered in time
• no officers available to escort the patient.

2.2.8 Healthcare staff told the investigation that patient engagement in their own health decisions could be low. Education and awareness of the risks played a part in the decisions that were being made by the patients. One prison had started to send healthcare staff to speak to the patient if they refused an appointment. Healthcare staff would explain to the patient the importance of attending and the effect that refusing treatment could have on their health and wellbeing. The staff told the investigation that engagement had increased and they had seen a drop in their non-attendance rates.

2.2.9 Where healthcare department appointment slips were used, the investigation was told that these were often delivered to patients late, or did not contain any information about what the appointment was for. In many of the prisons visited by the investigation, appointment slips were delivered by fellow prisoners. This meant that medical information was not included on the slip to avoid breaking medical confidentiality, adding a further complication to the routes of communication between the healthcare department and patients. Healthcare staff who had worked in other prisons stated that the same system had been used, and had caused the same issues, in those prisons. The investigation did not hear about the same issues within prisons that used an electronic booking system for the patients.

2.2.10 The investigation heard that there was variation in the amount of encouragement prison officers gave to patients to attend appointments. This was likely affected by the officers not knowing about the nature and importance of the appointments because of medical confidentiality. However, all healthcare appointments should be treated with the same degree of importance. Healthcare staff are the only people in a position to discuss specific treatments or tests the patient needs.

HSSIB makes the following safety observations

Outpatient appointments

Attendance rates

2.2.11 The investigation found large differences in attendance rates for outpatient appointments (see 1.4.9) between patients in the community and patients in prison. The investigation received attendance data from prisons it had visited, as well as national data (supplied by NHS England) that showed attendance rates from all prisons across the country.

2.2.12 Figure 3 shows non-attendance rates in 2023/24 of 26% for both males and females in the community, in contrast with 43% for male and 48% for female patients in prison (see 2.2.18). It shows consistency in attendance rates, which remained at similar levels for the last 2 years for both groups of patients. While the attendance rates for patients in prison were considerably lower than for community patients, the impact on the health service was not as large as this may indicate. Nationally there were almost 7 million DNAs for outpatient appointments, with patients from prison contributing 13,000 to that figure.

Figure 3 Outpatient appointment non-attendance rates

2.2.13 Across the male and female patients in prison, 25% of appointments that were not attended were cancelled by either the prison (see 2.2.14) or by the hospital. However, 20% of the appointments were not attended because the patient refused to attend. In the community the number of patients that did not attend was markedly lower at 6%, and the percentage of cancellations by healthcare services was also lower at 17%. These figures have remained consistent for outpatient appointments for many years, with the Nuffield Trust reporting almost identical figures for 2019/20 in their report ‘Injustice? Towards a better understanding of health care access challenges for prisoners’ (Nuffield Trust, 2021). Figure 4 shows the comparison between prison patients and patients in the community in 2023/24.

Figure 4 Overview of outpatient appointment attendance/cancellation for prison and community patients, 2023/24

Prison impact on patient attendance

2.2.14 The higher health services cancellation rate within prisons was mainly caused by appointments being cancelled by the prison healthcare department. The investigation was told that there were various reasons why the healthcare department would cancel appointments, which included:

• the prison regime clashing with the appointment – particularly the appointment time given by the hospital being outside of the prison officers’ escort availability hours
• the patient could not be located as they may be in a different location such as, a visit, court or at the workshop
• taxi/transport not turning up on time or being unsuitable
• the prisoners being restricted to their cells.

2.2.15 At one prison the investigation observed two wheelchair users who had been waiting for taxis to take them and their prison officer escorts to hospital, and who had had to cancel their appointments because the taxis were not wheelchair adapted. The healthcare staff said that they often had to cancel appointments because the transport either arrived late or was not suitable for the patients.

2.2.16 As with internal appointments, patients and healthcare staff described a lack of notice prior to patients being collected and taken for their outpatient appointments. Patients told the investigation that they were afforded little time to prepare themselves for the appointment and were given limited information about the appointment they were being taken for. Patients reported that the lack of communication meant they often forgot that they had been referred to an outpatient clinic and this would affect their decision making about attending the appointment.

2.2.17 Healthcare staff reported the same concerns about individuals’ level of awareness about their health and engagement with healthcare, and how this affected their decisions about attending clinical appointments.

2.2.18 While female patients were more engaged with healthcare for clinics within the prison, this was not the case for outpatient appointments. The DNA rate for female outpatient appointments was higher than for the males. The investigation found this was largely attributable to patient dignity issues (see 2.3.6). Healthcare staff described a reluctance among some patients to attend outpatient appointments which did not exist for internal clinics.

Informed consent

2.2.19 Patients must consent to treatment and this ‘must be voluntary, informed, and the person consenting must have the capacity to make the decision’ (NHS, 2022). Informed consent means:

‘… the person must be given all of the information about what the treatment involves, including the benefits and risks, whether there are reasonable alternative treatments, and what will happen if treatment does not go ahead.’ (NHS, 2022)

2.2.20 The investigation found that patients were being asked to go to their medical appointments and they were refusing, prioritising other activities or simply not wishing to attend. When this happened, in most cases, the patient had to sign a disclaimer that stated that they took responsibility for not attending their appointment. However, as stated previously, little information was given to the patient, and the prison officers collecting the patient were not aware of the nature of the appointment or the seriousness of the condition/appointment.

2.2.21 Other than in one prison, the investigation did not see or hear about a system where patient refusals were made with informed consent. Most patients were making decisions with very little information, particularly about ‘what will happen if treatment does not go ahead’. If they were informed then they may choose to prioritise healthcare appointments over their other activities.

Appointment rebooking

2.2.22 Prison healthcare admin teams told the investigation that they co-ordinate appointments for patients. If an appointment was missed and they were made aware in time they would advise the hospital. However, they often did not find out until afterwards. In this case they would speak to the hospital and try to rebook the appointment.

2.2.23 The admin teams generally described having good relationships with the hospital booking teams or the medical secretaries. This was important when it came to rebooking appointments as they felt they had a good understanding.

2.2.24 Healthcare staff described varying levels of understanding at hospitals when appointments were missed for reasons that were out of the patient’s control, such as a taxi being unable to collect them. Some hospitals were empathetic to the situation; however, they were aware of the regularity of the appointments being missed because the patient refused to go.

2.2.25 The investigation was told that patients were generally held to the three-strike rule for non-attendance of appointments (if they missed three appointments they were discharged back to their GP), regardless of whether this was in their control or not. There were occasions when patients were discharged back to their GP after one DNA, but this was not the normal process.

2.2.26 There were no formal agreements between prisons and their local hospitals about rebooking patients who had missed appointments. The rebooking of patients who had missed appointments was reliant on the relationships between the admin staff at the prison and the staff they dealt with at the hospitals.

Release from prison

2.2.27 HM Prison and Probation Service (HMPPS) and NHS England have worked together to ensure that continuity of care for patients who are being released from prison is maintained. The GP2GP service is part of the Spine (the shared NHS IT infrastructure) and was launched with the aim making it easy for medical records to be passed from one GP practice to another when a patient moves. Two of the stated benefits of the service are:

• ‘full electronic health records available for the patient's first and subsequent consultations, which improves continuity of care for ongoing medical conditions
• no need for patients to provide a detailed account of their previous medical history to their new clinician, as the integrated electronic health record is visible’. (NHS Digital, 2024)

2.2.28 To prepare for a prisoner’s planned release from prison, the investigation found that there was generally good co-ordination between services.

Healthcare and prison staff described meetings of organisations to discuss the patient and their needs. At these meetings the specific services the patient may need, such as substance misuse services or mental health services, were discussed and local arrangements were made to continue their treatment after release. However, patients described not knowing the processes or what was happening as they were not always involved in the meetings.

2.2.29 A national organisation stated that this system did not always work well and that there were times when people were released and the relevant community services were not aware of their needs. The investigation was informed that this generally occurred when people were released from prisons that were not in their resettlement area, meaning that the services they had received in prison that would be local to the person after release, were not represented at the meeting, or given the required information.

2.2.30 Healthcare staff described passing on medical information to patients prior to release, including the details of any outpatient appointments that were outstanding and any referrals that had been made for them. This information was also sent direct to the patient’s community GP as well through the GP2GP programme (which will be covered in more detail in the next HSSIB investigation within the prison healthcare theme, which will look at data sharing and IT), as long as the patient had registered with the GP2GP system and therefore had been allocated a GP in the community.

Release from court

2.2.31 The investigation was told that in cases where patients were released straight from court it was difficult to pass information to the patient about ongoing medical treatment and appointments. Patients held on remand will receive court dates and be taken to court to appear at their trials or sentencing. The outcome of these appearances may be that the patient (prisoner) is released straight from court. In this instance the patient does not go back to the prison as their belongings are taken with them in case this is the outcome.

2.2.32 The investigation heard that patients with booked outpatient appointments for treatment or tests were not made aware of these appointments before they attended court due to the security risks. If patients were then released direct from court there was no process in place to pass on information about any outstanding outpatient appointments. Of the healthcare departments that the investigation spoke to, some took action to try to pass the information on, either to the patient’s GP in the community or direct to the patient via a supplied address/telephone number. However, this was locally managed, relying on individual attitudes and diligence, rather than a national process.

2.2.33 The GP2GP programme allows information to be passed from one clinical information system to another, including details of any outstanding appointments; however, this would not be seen by the patient. This gap in information flow to the patient has resulted in missed appointments for treatment or tests, delaying appropriate care for the patient and increasing the DNA rate for the healthcare trust.

2.2.34 PSO 3050 states:

‘In cases where prisoners are released unexpectedly from custody there must be an agreed local protocol, where possible, ensuring continuity of care after release for patients with significant health problems. For example, contacting a prisoners’ GP/consultant where known.’ (HM Prison and Probation Service, 2006)

2.2.35 The investigation spoke with healthcare staff and prison officers who expressed concern about the continuity of care for patients being released from court. There is little detail in the PSO and it specifically mentions ‘patients with significant health problems’, whereas many patients who attend court have ongoing medical care that requires co-ordination and communication.

2.2.36 Chapter 7 of PSO 3050 deals with ‘release/discharge’ and states:

‘Where a prisoner is receiving medical care which needs to continue after discharge, it is important, as set out in the Transfer and Release Section of the Health Services for Prisoners Standard, that information to ensure continuity of care is communicated, with the prisoner’s consent, to his or her GP and/or other responsible community agencies on discharge. (see also para.7.6).’ (HM Prison and Probation Service, 2006)

Paragraph 7.6 of the PSO states:

'Where a prisoner who is receiving medical care that needs to continue after discharge, does not have an external GP, it is important that health care staff help the prisoner to register with one prior to discharge. Similarly, health care staff must arrange follow-up appointments with NHS providers for all continuing secondary health care needs, and supply medication appropriate to clinical need to ensure supply until a GP prescription can be obtained. (Resettlement PSO 2300).’ (HM Prison and Probation Service, 2006)

2.2.37 The PSO does not refer to the GP2GP programme and is written in the context of patients being released from a prison. Communication of healthcare appointments with patients, such as outpatient appointments or appointments for internal clinics, is not covered by the PSO. There are gaps in these processes that result in patients being released from court without knowing what healthcare appointments they have, which has resulted in further DNAs at local hospitals, but also in patients not continuing with their healthcare once released. PSO 3050 has not been updated since it was issued on 10 February 2006.

2.2.38 Category B local prisons, which have a high turnover of prisoners and many people being taken to court every day, expressed concerns about being able to ensure good continuity of care for patients. This was highlighted by data supplied to the investigation by one of the category B local prisons, which showed that nearly one third of its DNAs, in a 6-month period, were accounted for by patients who had either been transferred or released (see figure 5).

Figure 5 Reasons for patient DNAs in a 6-month period at a category B prison visited by the investigation

HSSIB makes the following safety recommendation

Prison patient dignity

2.3.6 Patients and healthcare staff told the investigation about issues of dignity when attending outpatient appointments. The common dignity issues reported to the investigation were:

• male and female patients being seen handcuffed in public and in prison clothing
• patients being escorted to outpatient appointments by prison guards of the opposite sex
• prison guards being present at the clinical appointment
• a lack of notice to enable patients to sort out personal hygiene and personal preparation for the outpatient appointment.

2.3.7 The investigation recognises the security requirement for patients from prison to be handcuffed during external appointments. However, both male and female patients commented to the investigation that being seen handcuffed in public, in prison clothing and escorted by prison officers, had an impact on their thought process when attending outpatient appointments.

2.3.8 The investigation heard that hospitals were concerned about other patients (the general public) feeling anxious about waiting with a prisoner in the room. One national organisation stated that it had heard of patients (prisoners) being made to wait in broom cupboards to avoid interaction with or being seen by other patients.

2.3.9 Healthcare staff from one of the female prisons the investigation visited, said that they had made efforts to try to reduce privacy and dignity concerns by using side entrances at one of the hospitals and not taking the patient into the hospital until the appointment was about to start. This removed the need to sit in a waiting room with other patients, which had helped to reduce the concerns of the patients from the prison, with a resulting improvement in appointment attendance.

Female patient dignity

2.3.10 The investigation was also told that female patients had dignity and privacy concerns, particularly when going to obstetrics and gynaecology appointments. One national organisation told the investigation that it had heard reports of a woman being handcuffed to a male prison officer while they were having a mammogram. Healthcare staff in the female prisons visited by the investigation stated that the prisons tried to only send female prison officers as escorts for patients going to obstetrics and gynaecology appointments. However, they said this was not always possible due to the limitation of staff availability. There was a higher percentage of male staff in one of the female prisons visited, which was said to make things difficult when it came to all-female escorts. Therefore, female patients may be escorted by either a mixed gender crew (one male and one female prison officer) or an all-male escort crew.

2.3.11 The investigation was told by HMPPS that they had an escort policy which made it ‘clear’ what was expected. They provided a copy of the policy, which was reissued in July 2024. The specific section of the policy that was relevant stated:

‘All HMPPS external escorts must consist of at least two prison officers, with at least one of them being the same legal gender as the prisoner, unless there are exceptional circumstances.’

‘In order to maintain decency, prisons are required to consider appropriate staffing in respect of gender for all hospital appointments, but particularly those that are related to gender specific services such as gynaecology.’ (HMPPS, 2024)

2.3.12 While the policy goes some way to detailing the expectation for sensitive female outpatient appointments, there is sufficient latitude that female patients may be escorted by escort crews containing male prison officers to any appointment, depending on staffing levels. The investigation did not observe a shortage of female prison officers that would appear to have restricted the escorts on those days.

2.3.13 Some actions had been taken to try to address privacy and dignity concerns, such as male prison officers staying outside clinical consulting rooms while patients were being treated. This did not always reduce patients’ concerns, as the male officers were still aware of what the appointment was for. The investigation was told that for some female appointments, any male officer on the escort crew could result in a patient declining the appointment.

2.3.14 In addition to their concerns about privacy and visual dignity, patients and healthcare staff told the investigation that personal hygiene was not taken into consideration. This was particularly the case for women who were going to obstetrics and gynaecology appointments. The women stated that they wanted to shower before these appointments but were not given enough notice. Typically they were collected from their cells and told to get ready and taken to be escorted to their appointment. This was cited as a reason for not attending appointments.

Medical confidentiality

2.3.15 The privacy and dignity concerns described by national organisations, healthcare staff and patients were also complicated by the issue of medical confidentiality. Patients often had their clinic appointments with prison officers in the clinic room, removing patient medical confidentiality. The investigation was told that some patients were put on an 'escort chain' which meant the officer could sit just outside the room while still attached to the patient; however, this was still within earshot of the conversation between the patient and the clinician.

2.3.16 In addition to the other dignity issues, the lack of medical confidentiality added to the likelihood that patients would not attend their outpatient appointments.

HSSIB makes the following safety recommendation

ABL Health (2024) Emergency care (Unpublished independent report commissioned by HSSIB).

Health and Social Care Act (2012) (UK Public General Acts). Available at https://www.legislation.gov.uk/ukpga/2012/7/contents (Accessed 17 July 2024).

Healthcare Safety Investigation Branch (2019) Management of chronic conditions in prison. Available at https://www.hssib.org.uk/patient-safety-investigations/management-of-chronic-health-conditions-in-prisons/investigation-report/ (Accessed 31 July 2024).

HM Prison and Probation Service (2006) Prison Service Order 3050. Continuity of healthcare for prisoners. Available at https://assets.publishing.service.gov.uk/media/5f7445ece90e0740cd69dfd6/PSO_3050_continuity_of_healthcare_for_prisoners.pdf (Accessed 14 August 2024).

HM Prison and Probation Service (2024). Prevention of Escape – External Escorts. Available at https://assets.publishing.service.gov.uk/media/6710d18892bb81fcdbe7ba04/prevention-escape-external-escorts.pdf (Accessed 11 November 2024).

House of Commons Health and Social Care Committee (2018) Prison health. Available at https://publications.parliament.uk/pa/cm201719/cmselect/cmhealth/963/963.pdf (Accessed 31 July 2024).

Martin, E. (2015) Oxford Concise Medical Dictionary, ninth edition. Oxford University Press.

McFadzean, I.J., Davies, K., et al. (2023) Patient safety in prisons: a multi-method analysis of reported incidents in England, Journal of the Royal Society of Medicine, 116(7), pp. 236-245. Available at https://pubmed.ncbi.nlm.nih.gov/37196674/ (Accessed 10 September 2024).

Ministry of Justice (n.d.a) About us. Available at https://www.gov.uk/government/organisations/ministry-of-justice/about (Accessed 17 July 2024).

Ministry of Justice (n.d.b) Working in the prison and probation service. Your A-D guide on prison categories. Available at https://prisonjobs.blog.gov.uk/your-a-d-guide-on-prison-categories/ (Accessed 10 April 2024).

National Prison Healthcare Board (2019). National Prison Healthcare Board principle of equivalence of care for prison healthcare in England. Available at https://assets.publishing.service.gov.uk/media/5d9dd37fed915d354bdf91d4/NPHB_Equivalence_of_Care_principle.pdf (Accessed 17 June 2024).

NHS (2022) Consent to treatment. Available at https://www.nhs.uk/conditions/consent-to-treatment/ (Accessed 9 September 2024).

NHS Digital (2024) GP2GP. Available at https://digital.nhs.uk/services/gp2gp#about-this-service (Accessed 16 August 2024).

Nuffield Trust. (2021) Injustice? Towards a better understanding of health care access challenges for prisoners. Available at https://www.nuffieldtrust.org.uk/sites/default/files/2021-10/1634637809_nuffield-trust-prisoner-health-2021-final.pdf (Accessed 4 November 2024).

The investigation report ‘Management of chronic conditions in prisons’ (Healthcare Safety Investigation Branch, 2019) identified areas of healthcare which were out of scope for that investigation that would likely warrant an investigation. To identify topics for investigation within the healthcare provision in prisons theme, the investigation reviewed intelligence from service and professional regulators, national reports, academia and research. Discussions also took place with a large number of national stakeholders to understand their concerns in this area.

Evidence was collated and analysed to identify common areas across the stakeholders, which were directly related to patient safety concerns. These areas were then placed into a hierarchy based on the number of stakeholders that mentioned it, the breadth of the concern across the prison estate, whether it affected male and female prisons and the estimated seriousness of the concern. As a result of this work the investigation was formally launched in February 2024 looking at three main topics:

• emergency care response
• continuity of care
• data sharing and IT.

Evidence gathering

The investigation undertook a programme of visits that was designed to be as efficient as possible and to account for all aspects of the prison estate, covering all three topics. All evidence was grouped into the different topic areas for analysis.

The investigation undertook site visits that covered:

• category A to D prisons (male) and closed prisons (female)
• prison buildings of a range of ages (1800s to 2020s)
• four geographical areas across England (south-east, midlands, north-west, north-east)
• three prison operators
• four prison healthcare providers.

The investigation engaged with:

• prison officers and security staff
• prison management
• ambulance crews
• emergency centre call handlers and dispatchers
• national and local commissioners
• healthcare staff and healthcare provider management.

Stakeholder engagement and consultation

The investigation engaged with stakeholders to gather evidence and check for factual accuracy, and for overall sense-checking. The stakeholders contributed to the development of the safety recommendations based on the evidence gathered.

Table A Investigation stakeholders