National Assembly for Wales

Diolch, Chair. Good morning. Just looking at the numbers, to start with, how significant do you think the number of complaints you get about health and social care from prisoners in Welsh prisons is?

Well, our written evidence outlined my role, and my remit doesn't extend to complaints about healthcare. So, complaints that we receive from people in prison about healthcare, we refer on to the—. In English prisons, we refer on to the Parliamentary and Health Service Ombudsman, and it has been an issue for complaints about healthcare from people in prison in Wales as to where those complaints go, particularly for Parc prison, which is run by a private contractor, as you know. So, we don't receive complaints, or deal with complaints, about health, but what we did do was contribute to a conversation about where complaints about healthcare from prisoners in Parc could go. And I understand that that has now been resolved satisfactorily, so that there is a part of Her Majesty's Prison and Probation Service that will pick up complaints, independent of the contractors.

So, you think that situation's resolved.

My understanding is that a structure has been put in place, but I would suggest it's early days to review how successful it's been. I mean, I would suggest that there ought to be a review of how successful it's been because it was unprecedented for Wales. So, it's a brand-new system that will need some evaluation.

Okay. So, would that be in line with other prisons in England and Wales? Would that bring it in line with that? Is that the system that would be in place?

Yes.

Okay. I think you've been clear on your first few questions. So, how are concerns escalated? Because, at the moment, we heard—when you were talking about HM Parc and the healthcare inspectorates—we heard that there was no clear inspection oversight for primary health care provision at Parc. So, how are the complaints escalated, or how did that work? Or how do you envisage that working?

Well, for public sector prisons in Wales—so, every Wales prison, apart from Parc—it's straightforward and the system is well established. My understanding is that what's been put in place now for HMP Parc is that where complaints can't be resolved by the provider—. So, all complaints about anything would be dealt with at local level first, so that would be the provider, which in this case is G4S healthcare. They would be escalated to a directorate within HMPPS Wales. So, that is part of the HMPPS structure, independent of the contractors, but also independent of the people who monitor compliance against the contract. So, it's as independent as it can be within the structures available.

Okay, happy? Yes, great. Moving on to Angela.

Yes, sorry. I'd like to talk about some of the investigations that you've done into the deaths of prisoners who have—or fatal incident investigations. Could I just ask you probably a slightly more random question? When you investigated those findings, was a contributory factor at all the difficulty of prisoners' health records being able to be accessed so that there was a clear understanding of the challenges facing that prisoner, whether it was mental health issues or physical health issues? Because one of the evidence sessions we had with the Royal College of Nursing was actually quite clear—and I also think the British Medical Association may have said it, or somebody else did—they were very clear about the fact that, because prisoners move around the estate so often, it's very hard for their records to keep pace with them. Do you think that was a contributory factor at all?

Yes. We have certainly identified in a number of our fatal incident investigations into deaths in Welsh prisons that the ready availability of medical records is an issue, both to allow people providing healthcare to have accurate, up-to-date information about need, but also when we come to carry out our investigations in terms of being able to provide us with the necessary information to do our investigation. So, yes, we have identified that as one of the themes. It's not one of the most common findings that we make when we investigate fatal incidents, but it is something that comes up and has come up more than once, that, as you say, because people move around from prison to prison or from community to prison, it can take time for medical records to follow. And sometimes, there are issues about the technology, the compatibility of technology that allows practitioners in prisons to have immediate and accurate access to data.

Of course, the other thing that you identified in fatal incident investigations was also that the healthcare provision was not equivalent to that in the community—these were the ones, obviously, at HM Parc. And again, I'm just trying—. I've got my fingers everywhere here, because I'm also trying to find the evidence that came from the Royal College of Nursing: a survey undertaken with nurses who work in prisons. Sixty four per cent said that

'care was compromised on their last shift'.

And of all respondents to the survey, those working in prisons rated the quality of care most poorly. That seems to chime with your commentary and your evidence. Would you like to expand on that a little bit further?

Certainly. First of all, when we carry out our fatal incident investigations, we do them alongside clinicians who do what we call a clinical review, and that clinical review is an appendix to our report. So, the clinical aspects of the fatal incident are investigated by an appropriate clinician who will be commissioned by Healthcare Inspectorate Wales—so, somebody independent of the health providers. But we work in tandem with them and we carry out joint interviews and we do the investigation together.

But, one of the crucial things that we look for is about the equivalence of healthcare delivery. So, what we assess is whether the healthcare that somebody received whilst they were in custody is equivalent to the healthcare that they should have received in the community. And often, what we believe we ought to be looking at is that it is at least equivalent. Because we know that, sometimes, actually having somebody in prison is an opportunity to deliver them better healthcare than they might have been in a position to access, and that's particularly things like dental care and things like smoking cessation and substance abuse support. So, we look for equivalence.

But in a significant number of cases, we've found that healthcare was not equivalent and there are a number of reasons why that is found to be the case. Sometimes it is, as we've said, about good information—the right information to allow for the right needs assessment to be carried out. Sometimes it is about the right staff being available, and recruitment and retention of healthcare staff in prisons is a challenge. Sometimes it is about equipment; sometimes it's about training, that sometimes the clinical staff haven't got the right up-to-date training to allow them to deliver the right care; and sometimes it's about a disconnect between the community and the prison, so it's about the absence of any continuity of care.

We always look for this issue of equivalency, and we always comment on it in our fatal incident investigations. Where we find that it's not equivalent, we make recommendations as to what needs to be done. Those recommendations go to the head of healthcare and the governor or director in the prison. If necessary, if we find that we're finding the same failings again and again, we can escalate our findings and recommendations, either to the prison group director or to a more senior person in the healthcare chain, and we do that now more often than we used to.

And of course a consequence, perhaps, of not having the right particular mental health treatment is that we see self-inflicted deaths, as you put it in your evidence, and you said that between 2014 and 2018 you've opened 16 investigations into self-inflicted deaths. Do you have a view on how successful we are being at ensuring that people are appropriately put into prison, and that those with mental health issues who perhaps should not be there aren't just being warehoused there because there is nowhere else to go? Again, we've had commentary from different witnesses who've raised that as a concern, and I just wondered whether or not you felt that there was enough being done to divert people away from a prison environment.

Well, first of all, that's outside my remit, so issues around sentencing and whether prison custody is the appropriate sentence is outside my remit. But what we do find is that there are a number of organisations who are very vocal about the absence of suitable community alternatives to custody, and we know that there are instances where people are sentenced to prison custody because there is no alternative, so either as a place of safety or as a place where they might receive treatment where there isn't an appropriate healthcare alternative. So, it's not in my remit to say. We don't comment on that, but certainly we find that there are numbers of people in our fatal incident investigations who are very unwell and need a level of support that we find can't be delivered in a prison setting.

I just want one further question, which again I appreciate you may not be able to answer, but you talk again in your evidence about the importance of continuity of care, and you're obviously the ombudsman for people in prison. Do you ever get any feedback or have data about prisoners who've literally just left prison, have just gone into the community, and either suffer catastrophic mental or physical health or indeed perhaps die by suicide or whatever? Do you get any of that feedback on those people on the cusp?

It's a really timely question for us because we are the Prisons and Probation Ombudsman, but we investigate every death in state detention, and that's an article 2 requirement under the Human Rights Act 1998, so there is a legal requirement for us to investigate every death in custody. In terms of post-release deaths and the deaths of people under probation supervision or in probation-approved premises, we have discretion as to whether we investigate those deaths. In practice, we investigate very few, partly because we don't have the resources and we have to prioritise those investigations that are a legal requirement, but also because we aren't as sighted: we don't have as much information on those.

We're having discussions at the moment as to how we can review our terms of reference and expand our terms of reference so that we might address those issues differently, particularly, as you say, the times when people take their own lives either shortly after release from prison or whilst they're under the supervision of probation or even in a hostel. So, we do investigate some, but because we investigate so few, we don't have as comprehensive an understanding of the issues. There is some really good research going on in academia into post-release deaths and we're tapped into that now, and we've had some really good conversations with academics about how we might contribute to that debate. But I think we should be doing more. We could be doing more, but we will either need to ask for additional resources or we'll need to stop doing something that we're currently doing to make space for that.

Thank you.

David, you've got a supplementary.

Just a very short one. And I appreciate your remit, and I appreciate the work you're now doing with academia to look at deaths following release. But do you have an indication as to whether this is escalating? Have you seen a trend increasing in the number of deaths following release? Because you might not investigate it, but you surely should know how many occur.

Yes. And, again, my understanding from the conversations that we've had, and what I've read recently, is that there is a rise in the number of people dying under probation supervision and a suggestion that that may be connected in some way to the availability of psychoactive substances, for example. But it is a rising trend, just as it is in custody.

So, is it in relation to the rise in psychoactive substances, either within prison or when they leave prison, but also is there an issue as to suicides and their increase in number because of perhaps the failure of mental health services within the prison?

We don't know that. And we don't know that because we haven't got that comprehensive data set to back that up. I would suggest that it's a whole range of issues. So, where you're talking about people dying within a very short time of being released from prison, the inference would be that it may be about continuity and about what support has been given to the person as they go through the gate. But I think it's a whole lot more complex than that, and we would need to do a lot more work to understand that.

Diolch, Cadeirydd. Thank you. In response to Angela Burns, and in your written evidence, you've talked about the importance of accurate record keeping and good information sharing, and the problems that arise when that doesn't happen. Is there anything you'd like to add about how that might be improved? Because one of the things we try and do on this committee is to be positive, and to make suggestions about how we might make things better, as well as highlighting what's difficult.

I'm not an expert on the way that the systems work. But I think what we have found is that there are some potential technological solutions, if there was a single platform. But I think also it's about—and this is not just restricted to healthcare record keeping; it's probably more comprehensive than that—readiness to share information, and about where there are protocols in place to make sure that information, where it's appropriate, and understanding the need for confidentiality in some ways, but where information can be shared. So, I think a more open commitment to sharing information would be helpful, but also everybody understanding their responsibilities in terms of recording things. So, sometimes, it's not only that the information is not shared, it's that the information is not recorded and not available. And that may be a training need or it may be a culture need; it's sometimes that people are very pressed, so they don't record things. But I think better record keeping and better record sharing is really important.

Thank you. That's really helpful. So, the partnership agreement for prison health in Wales has its four key priorities: promoting health and well-being; mental health; substance misuse; and medicines management. Do you have a view as to whether these are the right priorities to help address the concerns that your work has raised?

I would suggest that they are. I think that the issue of substance misuse is absolutely key at the moment, and we're certainly finding that it's a thread throughout our fatal incident inquiries now, which is about the support given to people. And I know there have been some issues about the disconnect between the support available in prisons in England and in prisons in Wales. I think the concerns have been well aired already, about when people transfer from prisons in England to prisons in Wales, and about how they can continue to access the same support. But I would suggest they are the right four priorities. But for us, in terms of our non-clinical input into those, the substance misuse one is particularly key.

And is it your sense that, given that those are the formal priorities—is the service reacting to those? Because it's one thing to have your priorities in a document and it's another thing when you’re the healthcare worker and you’ve got people coming at you from all angles. Are those priorities able to be treated as priorities by the people actually delivering on the front line?

Again, it’s a very timely question, because we’re just in the process now of looking at our budgets for next year, and I think, without wanting to sound like a broken record, much of it does come down to resources. I know there have been real challenges in, particularly, Parc—that's my understanding—about the availability of resources to deliver healthcare. The reality is, if resources are put into that, they have to come from somewhere else, so I understand the tensions. But there is no doubt that having fewer resources, having less money, means fewer staff, and that represents a real challenge. So, I think it is very difficult. I’m an optimist by nature and I think people are doing the best they can with the resources they’ve got, but we are seeing regimes very stretched, we’re seeing healthcare delivery very stretched, and that inevitably impacts on safety and on the quality of delivery at the front line.

Thank you, that’s helpful. One of the issues that isn’t one of the priorities is addressing the needs of older prisoners. Do you feel that that should perhaps have been one? And, again, that may be something that we might wish to recommend.

Yes. You will know that the number of people in prison over the age of 50 is going up very, very quickly. And the number of people in prison over the age of 70 is now rising. We’re seeing people being sentenced to lengthy periods in custody when they’re elderly and have chronic healthcare needs—sometimes a terminal diagnosis, for example.

We have been saying for some time that there needs to be a strategy for the care of older people in prisons, and there still is no national strategy, so what we see is that prisons individually are doing the best they can. And there is some really good work going on, but it is piecemeal and it is not really joined up. So, we would say that it is a health and social care need, of course it is, but it is also an operational need. So, it’s a shared need for HMPPS and for the healthcare providers.

Again, we know that there is some really good work going on outside of the prison service to look at whether units for older people are the right way to go. There is a suggestion that it’s not perfect, because some older people prefer to be in the general population with younger people, but there is some evidence that, where individual prisons have decided to have older people’s units, they have been successful in terms of being able to support people and provide care for, for example, people with dementia or for people with very, very serious and chronic healthcare needs. But there is currently no national strategy, either from the healthcare side or from the operational prison service side, which means that—it’s seen as a priority, but it’s not identified as such in terms of developing a strategy. So, we’ve been recommending it for a long time. You may want to support that recommendation.

Thank you, that's helpful. You may not be able to have a view about this, but would it be your view that staff in prisons are adequately supported to deal with this very particular group of older prisoners? As you say, some of them may be at the point certainly of developing physical health needs, but also dementia. Is there support or is there somewhere where we should look for some good practice on this to highlight?

Well, we've identified, through some of our reports, that prison officers are trained to do one job and then sometimes are put into a prison and asked to do something completely different, and looking after older people is a good example of that. Again, we see examples of really good care being delivered. I've visited prisons and seen older prisoners being very well supported, both by prison staff, by healthcare staff and by other prisoners in supporting roles, but there is no element of the initial prison officer training that talks about how you support older people, and, as far as I'm aware, there is no ongoing training for them. So, it is a big ask for some people. So, no, the structures aren't in place to deliver good geriatric and social care. So, again, it tends to come from either individual officers or individual prisons that do the best they can, but sometimes without the right tools.

Thank you, that's helpful. HMPPS in Wales has called for a new Wales prison health board to be established by Welsh Government to provide strategic planning for prison health in Wales. Do you have a view about this suggestion in terms of whether it might improve oversight and accountability for prison healthcare in Wales and might assist in avoiding some of the deaths that you've had to investigate?

My view is I would want to understand how it would make oversight more effective, and I'm not a fan of bureaucracy for bureaucracy's sake. So, there is always a danger that you set something up and just make the whole landscape more complicated. And that means that more of the resource is going into the governance and less into the delivery. So, I think it would need to be clearer. I think it would be a very positive statement that it's seen as a priority. So, my instinct is it could be a good thing, but it needs to be as simple and as well understood and as unbureaucratic as a bit more bureaucracy can be, if that makes sense.

Yes—I'm smiling because I completely understand. And, of course, there is a tendency, a bit, sometimes, for Governments to set up a board and they think they've done something, but, actually, it doesn't change anything for the people on the ground.

If there were one or two issues that you would like to see urgently addressed to help improve the physical and mental health of prisoners in Wales, what would those be—if there was one thing that we could tell the Welsh Government that they really needed to work with the prison service to do?

Well, I've mentioned already the higher numbers of older people in prison. So, as I say, we've been calling for a strategy, so I think there needs to be a clear understanding of what is expected—what we're expecting the prison service and their partner agencies to deliver to these older people when they're in custody. Some of these older people are coming to prison for a very, very long time; some for the rest of their lives. So, what meaningful care and regime and provision can be delivered to those people? So, I think that would make a real difference, and that would make a difference to what we find in our fatal incident investigations.

So, it's not just about preventing deaths. Our fatal incident work isn't just about preventing deaths; it's about making sure that that end-of-life care or that care that's given to somebody in the later years of their lives is as good as it can be, and as equivalent as it can be. So, I think that would be a priority for us. And I think that that would allow for a more appropriate use of the increasingly scarce resources as well—if that could be better directed. I think also, in terms of some of the findings that we have made in our fatal incident investigations, there perhaps needs to be a more creative use of compassionate early release and care outside of prison at the end of life as well. So, there are arguably people dying in prison who ought not to die in prison.

Thank you.

As you say, the whole issue of substance misuse is a big one for us in our fatal incident investigations, and also for HMPPS. In terms of the reduction in the supply of drugs, there is a lot of good work going on in some prisons around using technology to detect drugs coming into prisons. Hopefully, prisons in Wales will have access to some of that technology soon, because it's been shown to be very successful—the body scanners, the equipment that can scan mail and other items that are used to conceal drugs.

In terms of healthcare, it is less about the reduction in supply, and more about the reduction in demand, so it's working with people to address their addiction issues. As far as I'm concerned, from our fatal incident investigations, we do find that there are some deaths from accidental overdose of drugs, and occasionally from deliberate overdose of drugs. But, often, we also find that drugs are implicated in deaths in prison. So, it may be that there is either trading in prescription medication—so, illicit use of medication that's in the prison—or that people have long-standing addiction, and their drug addiction actually exacerbates other medical conditions, and that the combination of those things results in a fatal incident.

We've talked already about how one of the priorities is medicine management. So, there is a real need for medicines to be properly administered and securely monitored. Some people in prison, some prisoners, will be allowed to have their own medication in possession and administer it to themselves, as they would in the community. But there need to be robust systems in place to make sure that only people who are safe to do that are allowed to do that, and that robust systems exist elsewhere to make sure that medication is dispensed appropriately, and that people don't have the opportunity to trade it. That's very difficult, because you can't always prevent people who are very determined to do that. That is a real challenge.

Also, it's about providing the sort of support for people who do want to address their addictions. I talked already about how, sometimes, prison is an opportunity for people to do work that they might not otherwise do on addressing addictions, and, sometimes, that's really, really difficult. We see that people say one thing, and they say they want to address their addiction, but, actually, we find that they continue to use drugs. So, I don't underestimate the challenge.

What our job is to do is to identify, when we investigate a fatal incident, where that has been an issue and, crucially, to make recommendations, based on what we know from that investigation and others, about what can be done and should be done to address it. One of the challenges we have is that we make recommendations, not just to healthcare providers, and we don't have a way of following up on how those recommendations are implemented. So, we're talking about how we might either word our recommendations differently, or manage them differently, so that we have a better way of tracking and supporting the agencies in question to deliver.

Thank you. It was lovely to meet you. Thank you.