Too little too late

contents of a prison cell table showing a pill box, lighter, razor, cigarette ash and a food plate

Too Little, Too Late: An Independent Review of Unmet Mental Health Need in Prison, published by the Prison Reform Trust, reveals that many people who should have been diverted into mental health or social care from police stations or courts are entering prisons, which are ill equipped to meet their needs, and then being discharged into the community without any support.

The report, backed by the Mercers’ Company, draws on information and evidence provided by the Independent Monitoring Boards of 57 prisons. Board members are appointed for each prison by the Justice Secretary to monitor treatment of and conditions for prisoners across England and Wales. From the unique perspective of these boards, we see a system under pressure struggling to respond to the complex needs of people, many of whom are in the wrong place. Earlier intervention, well-resourced mental health and social care in the community, residential care or, in some cases, in-patient or secure psychiatric provision could all have saved vulnerable people from the rigours of imprisonment.

The chair of one board described the distressing situation for one elderly man and prison staff charged with his care:

An 80-year-old confused man [in this prison] is unable to look after himself. We do not yet know whether he was known to social services but it seems likely. He has a five-year sentence for indecent exposure which is not surprising since he continually takes his clothes off.

Another board gave the following example:

A young female who . . . had a mental age of a young adolescent, because of each prison wishing a respite from her activity, was sent to [this prison], where she was retained in the segregation unit for over 28 weeks.

A third reported:

Between the dates of June 8th and 23rd this year, there were seven cases of self-harm, and two of attempted suicide. To quote our incident report sheet, “A made several cuts to both arms with a razor blade. Treated by a nurse and then relocated to the HCU. The cell was sealed off due to the amount of blood on the floor and furniture”. There will be no other treatment available to aid recovery. 

Commenting on the report Juliet Lyon, director of the Prison Reform Trust, said:

This unique report raises searing questions about why we lock up our most ill people in our most bleak institutions. Why waste time and public money building bigger and bigger prisons when it is clear that our jails are full of people in urgent need of proper mental health and social care?

Dr Peter Selby, President of the National Council for Independent Monitoring Boards, and former Bishop to Prisons, stated:

There is no more distressing a mismatch in our criminal justice system than mental illness and prison. Would anybody prescribe for a mentally ill person the kind of environment that a prison needs to be, let alone the kind of environment that actually exists in our oldest and most unsuitable prisons? Yet this mismatch is what tens of thousands of prisoners experience.

Improvements made since the NHS assumed responsibility for prison healthcare are acknowledged by some boards. Prison staff and managers are commended for coping well in trying circumstances. Overall however the report reveals the extent to which mental health needs in prison are being neglected. Out of 57 Independent Monitoring Boards who responded:

    * Over twenty boards specifically stated that they frequently saw prisoners who were too ill to be in prison.
    * Only one in six of the boards who responded rated the resources available for mental health care as good or adequate.
    * Just over half of boards who responded stated that they were aware of serious delays in arranging for transfers of prisoners  identified as severely mentally ill and who should be promptly transferred to appropriate NHS care.   
    * Nearly a third of boards who provided information felt that resettlement and continuity of care were lacking on release.

Boards expressed concern that symptoms of mental illness are often treated as a disciplinary rather than a medical or treatment issue, and mentally ill prisoners are confined in segregation units.  One board reported:

Too often we observe prisoners whose extreme, often bizarre, behaviour patterns present serious control problems within the prison. Such prisoners usually end up in the segregation unit, where their disruptive behaviour often continues.

Particular concerns were expressed about the inappropriateness of prison for people with learning disabilities and those suffering from dementia, as these instances reported by two boards show:

A prisoner who had a clinically assessed mental age of between two and five years of age . . . was cared for in the CSU [care and separation unit] and his toileting and washing needs were met by nurses until he was transferred out of the prison.


[An older] man is withdrawn and unable to look after himself.  He almost certainly has an organic dementia.  He is an IPP prisoner who is quite unable to co-operate in any courses even if they were available and this means that he will remain in prison indefinitely unless somebody intervenes. 

A disappointing finding was that not one of the boards responding stated that families were involved in decisions about mental health care as a matter of course. This demonstrates that Independent Monitoring Boards who visit prisons regularly and are on call all the time have witnessed conditions that echo the findings of the Chief Inspector of Prisons in her recent thematic review of mental health in prison.

The report makes a number of recommendations for change including:

    * A national network of court and police diversion and liaison schemes should be established, with performance targets and sustainable funding.
    * Every prison should have learning disability specialists, providing a better assessment service, improved conditions and treatment, and follow-up support.
    * Prison resettlement units and probation officers should alert Local Authorities to their duties to assess the needs of vulnerable prisoners at an early stage well before they are released from prison.

The Prison Reform Trust publishes this report as Lord Bradley prepares to submit to ministers the findings of his year- long, government-commissioned review of the diversion of people who are mentally ill, or suffer from learning disabilities, away from the criminal justice system into appropriate health or social care.