Patient safety in prisons: a multi-method analysis of reported incidents in England

Author:

McFadzean Isobel J1ORCID,Davies Kate1,Purchase Thomas1ORCID,Edwards Adrian2,Hellard Stuart1,Ashcroft Darren M34,Avery Anthony J45,Flynn Sandra6,Hewson Tom6,Jordan Melanie7,Keers Richard348,Panagioti Maria49,Wainwright Verity6,Walter Florian6,Shaw Jenny6810,Carson-Stevens Andrew2

Affiliation:

1. Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, CF14 4YU, UK

2. PRIME Centre Wales, Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, CF14 4YU, UK

3. Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, University of Manchester, Manchester, M13 9PL, UK

4. NIHR Greater Manchester Patient Safety Translational Research Centre (PSTRC), University of Manchester, Manchester, M13 9PL, UK

5. Centre for Academic Primary Care, School of Medicine, University of Nottingham, Nottingham, NG7 2UH, UK

6. Faculty of Biology, Medicine and Health, Centre for Mental Health and Safety, University of Manchester, Manchester, M13 9PL, UK

7. School of Sociology & Social Policy, University of Nottingham, Nottingham, NG7 2RD, UK

8. Greater Manchester Mental Health NHS Foundation Trust (GMMH), Manchester, M25 3BL, UK

9. Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, M13 9NT, UK

10. Independent Advisory Panel on Deaths in Custody, London, SW1H 9AJ, UK

Abstract

Objectives Prisoners use healthcare services three times more frequently than the general population with poorer health outcomes. Their distinct healthcare needs often pose challenges to safe healthcare provision. This study aimed to characterise patient safety incidents reported in prisons to guide practice improvement and identify health policy priorities. Design: We carried out an exploratory multi-method analysis of anonymised safety incidents from prisons. Setting Safety incidents had been reported to the National Reporting and Learning System by prisons in England between April 2018 and March 2019. Participants Reports were reviewed to identify any unintended or unexpected incident(s) which could have, or did, lead to harm for prisoners receiving healthcare. Main outcome measures Free-text descriptions were examined to identify the type and nature of safety incidents, their outcomes and harm severity. Analysis was contextualised with subject experts through structured workshops to explain relationships between the most common incidents and contributory factors. Results Of 4112 reports, the most frequently observed incidents were medication-related (n = 1167, 33%), specifically whilst administering medications (n = 626, 54%). Next, were access-related (n = 559,15%), inclusive of delays in patients accessing healthcare professionals (n = 236, 42%) and managing medical appointments (n =  171, 31%). The workshops contextualised incidents involving contributing factors (n = 1529, 28%) into three key themes, namely healthcare access, continuity of care and the balance between prison and healthcare priorities. Conclusions This study highlights the importance of improving medication safety and access to healthcare services for prisoners. We recommend staffing level reviews to ensure healthcare appointments are attended, and to review procedures for handling missed appointments, communication during patient transfers and medication prescribing.

Funder

National Institute for Health Research

Publisher

SAGE Publications

Subject

General Medicine

Reference30 articles.

1. A critical examination of the health promoting prison two decades on

2. Ministry of Justice and HM Prison and Probation Service. Prison population figures: 2021. Gov.UK; 2021. See www.gov.uk/government/statistics/prison-population-figures-2021 (last checked 3 October 2022).

3. Penal Reform International. Global Prison Trends. May 2022. See www.penalreform.org/global-prison-trends-2022/ (last checked 3 October 2022)

4. World Health Organization. Prisons and Health. Regional Office for Europe; 2014. See https://apps.who.int/iris/handle/10665/128603 (last checked 3 October 2022).

5. Mental and physical health in prison: how co-occurring conditions influence inmate misconduct

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