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Laura Abbott and colleagues highlight gaps in clinical care for pregnant women in prison and consider how best to meet their needs.

This is the second in a series of reports by the Health Services Safety Investigations Body (HSSIB) on the theme of healthcare provision in prison. The first investigation focused on the delivery of emergency care. This investigation looks at improving patient safety in relation to continuity of care for patients detained in prison. In the context of this investigation, ‘continuity of care’ means maintaining a patient’s healthcare throughout the prison system regardless of their location. The investigation considered the movement of patients between prisons, to and from court, and on release. It also looked at patient attendance at appointments for internal primary care services and secondary care outpatient appointments. Findings of this report include: ‘Did not attend’ (DNA) rates for outpatient appointments for patients in prison during 2024 were high, at 52% and 57% for males and females respectively. This compares to a DNA rate in the general population of 26% for both sexes. Female prison patients are often taken to outpatient appointments by male prison officers or a mix of male and female officers. This can affect the patients’ decision making about whether to go or not, particularly for appointments that are for sensitive female clinics such as obstetrics and gynaecology. The use of telemedicine in prison healthcare has declined since the end of the COVID-19 pandemic and it is used rarely in comparison to face-to-face appointments. Telemedicine has the potential to reduce the burden of prison officer escort duties for outpatient appointments (which costs £48m to £50m per year), increase the number of outpatient appointments available per day to patients in prison, and reduce the number of appointments that patients refuse to go to. Patients in prison may not attend pre-arranged appointments because of a lack of information about the appointment caused by privacy and security issues. For example, they may not be informed about timings, the nature of the appointment, or the health reasons and importance of attending. This means they are not able to make an informed decision about their health and whether they want to attend or not. Patients in prison are more likely to miss outpatient appointments than patients in the community, due to the prison regime and logistics beyond the control of the patient. Prison healthcare departments rely on relationships they have developed and maintained with hospital booking teams in order to arrange appointments that fit in with the prison regime. This is due to a lack of formal arrangements between prisons and their local hospitals. Patients who are released following a court appearance, who had treatment planned, are not routinely given information about upcoming appointments they may have. This means they may unknowingly miss booked appointments, delaying their care and treatment. Details about patients who are being transferred to different areas are not always communicated effectively between prison healthcare teams and hospital booking teams. Often hospital booking teams are not made aware that a patient has been transferred until an appointment is missed, which means treatment is delayed. In this report HSSIB recommends that: HM Prison and Probation Service updates Prison Service Order 3050, ‘Continuity of healthcare for prisoners’, including guidance on communication of information about prison patients when transferring between prisons, and on the process when prison patients are released from court. This will reduce variation and ensure better continuity of care for patients when being transferred or on their release. HM Prison and Probation Service standardises the approach to the provision of prison officer escorts for outpatient appointments to protect the dignity of patients and reduce variability of escort slots. This will assist in reducing the likelihood of patients refusing to attend healthcare appointments, while balancing appointment availability, thus improving the continuity and equality of care. NHS England, via regional commissioning teams, works with HM Prison and Probation Service to identify barriers to using telemedicine for outpatient appointments, and then implements local solutions to promote and enhance the capability and usability of telemedicine. This aims to reduce the burden on prisons of providing escorts and the likelihood of patients not attending appointments.

This report makes several recommendations to unlock the preventative potential of Prevention of Future Deaths (PFD) Reports. These reports should be viewed as an opportunity for organisations to improve, share good practice, and ultimately prevent custodial deaths – not as criticism to be avoided at all costs. PFD reports have an integral function in ensuring compliance with the state’s duties under Article 2 of the European Convention of Human Rights (ECHR), the right to life, both locally and nationally. This, as well as their immense importance to bereaved families, must be borne firmly in mind. Recommendations For Government departments, agencies, and private providers: 1. All should ensure that their approach to the PFD process is open, non-defensive and that the public interest in preventing future deaths is prioritised over reputational considerations at every stage. For example, lawyers should be specifically instructed not to take an adversarial approach to the making of a PFD report, and instead to neutrally present the evidence in order to assist the coroner. 2. All should ensure that they approach the PFD process with full candour and proactively provide all relevant information at the earliest appropriate stage. 3. The Ministry of Justice (MoJ) should adequately resource the Chief Coroner’s Office to produce a yearly review of PFD reports for custody deaths. This should aim to identify themes and trends, and report on the timeliness and quality of responses, as part of the Chief Coroner’s role under existing guidance.3 4. The MoJ should provide dedicated funding to the Chief Coroner’s Office to enable it to centrally record the conclusions of inquest juries, even where no PFD report is issued, and publish them online for easy referral in the same way that PFD reports are currently published. 5. The Department of Health and Social Care (DHSC) should give serious consideration to the creation of an independent body for investigating deaths of those formally or informally detained in mental health settings. This would remove the anomaly between the investigation of such deaths and those of persons in other detention settings andensure that coroners consistently have the benefit of high quality evidence regarding the circumstances of such deaths for the purposes of the inquest. 6. Recipients of PFD reports relating to deaths in custody should hold a “post-inquest learning review” meeting following the conclusion of an inquest, attended by the key persons who participated in the inquest. This will help to ensure both an efficient and fully informed response to PFD reports and the formulation of an appropriate action plan to take forward necessary learning. 7. Recipients of PFD reports should ensure that their responses are timely, high quality,case-specific, and fully informed by the inquest evidence and findings. Where the response relays that action will be taken, actions should be identified in precise termsand with precise timelines. Where no action is to be taken, a clear, detailed and respectfully worded explanation should be provided to enable the coroner, family, and wider public to understand the basis for the decision. Recipients should ensure that their responses recognise and reflect the significance of PFD reports to bereaved families, with consideration given to how families can be kept informed and where appropriate consulted on the action plan. 8. All should ensure PFD reports are shared ‘horizontally’ with relevant equivalents across the country – for example, other police forces, prisons, and mental health trusts –particularly where there may be scope for national learning, to ensure opportunities tomake change across different custody areas are not missed. 9. Leaders of local custody bodies, such as prison governors, should consider adopting the approach of Milton Keynes Together Safeguarding Partnership and hold periodic meetings of representatives from all custodial settings to review relevant PFD reports, with participation, where appropriate, of local coroners. 10. Government should consider what enhanced role independent bodies might play in auditing, following up on, and reporting on PFD reports, and this could include establishing a new body for this purpose. More effective oversight of the sharing, use, and implementation of matters of concern in PFD reports is needed. For the Chief Coroner and his Office: 11. The Chief Coroner should consider supplementing his guidance on PFD reports to further address when it may be appropriate, in compliance with the statutory requirements, to make interim PFD reports and the importance of doing so, in particular where a coroner is of the opinion that there is an urgent need for action to prevent future deaths. 12. The Chief Coroner should consider supplementing his guidance to advise coroners on the importance of ensuring relevant evidence is provided at a sufficiently early stage, inparticular where coroners consider there may be a need for urgent action. The guidance should remind coroners that previous PFD reports and evidence of ‘near-miss’ incidents may be relevant and important. 13. The Chief Coroner’s Office should review and consider expanding the list of organisations which should receive PFD reports on deaths in state custody (found at paragraphs 56 and 57 of the guidance on PFD reports) to ensure more comprehensive coverage of relevant bodies, organisations, and departments. This should be circulated to all coroners and used in training on PFD reports. The IAPDC could assist with ensuring this list is up to date and comprehensive. 14. The Chief Coroner’s Office should ensure that its online database of PFD reports is fully searchable by thematic areas and location, and that deaths in detention (particularly under the Mental Health Act 1983 (MHA) are readily identifiable. Consideration should be given to tagging reports according to the deceased’s protected characteristics to help better identify and understand issues of disproportionality. For other bodies with a key role to play in preventing custody deaths: 15. The Ministerial Board on Deaths in Custody secretariat should send PFD reports on deaths in custody to the House of Commons Justice, Health, and Home Affairs Select Committees, which should consider taking evidence and reporting on significant themes. 16. All organisations which scrutinise places of detention should make explicit use of PFD reports to inform their investigations, inspections, and thematic reports and bulletins, including monitoring and reporting on progress made against responses to PFD reports by services and agencies. They should work with the Chief Coroner to agree protocols to work together and share learning. 17. The Ministerial Board on Deaths in Custody (MBDC) secretariat should continue to review and distribute PFD reports relating to death in custody to MBDC members for the purpose of sharing learning, and consider involving all relevant agencies and partners who would benefit from additional learning across all places of state detention. Issues of significant wider concern arising from recent PFD reports should be discussed at MBDC meetings. 18. The Judicial College should work with the Chief Coroner to deliver mandatory training to coroners on the purpose, process, publication, and distribution of PFD reports, as well as the role of independent scrutiny bodies, incorporating the perspective of bereaved families. Read the full report via the link below.

Reducing avoidable healthcare-associated harm is a global health priority. Progress in evaluating the burden and aetiology of avoidable harm in prisons is limited compared with other healthcare sectors. To address this gap, this study, published in PLOS ONE, aimed to develop a definition of avoidable harm to facilitate future epidemiological studies in prisons. Authors conclude: "We have developed a working definition of avoidable harm in prison health care that enables consideration of caveats associated with prison environments and systems. Our definition enables future studies of the safety of prison healthcare to standardise outcome measurement."

Prisons and Probation Ombudsman Sue McAllister has published the independent investigation into the death of a baby (Baby A) at HMP Bronzefield on 27 September 2019. The investigation identified a considerable number of issues and concerns about the care and management of Ms A, the baby’s mother. Sue makes a significant number of recommendations to improve maternity services in Bronzefield. There is wider learning for the whole of the women’s prison estate from the death of Baby A, and the Prison Service must take this opportunity to improve the outcomes for pregnant prisoners so that this tragic event is not repeated. Click here to view the report Click here to view the action plan

There are estimated 24 000–60 000 women who are pregnant and incarcerated worldwide and they often lack access to antenatal care at the same level as that available in their communities. Despite clear international standards that mandate equivalent care for people in prison, pregnant women in these settings face significant barriers to adequate antenatal care. The needs of pregnant women are often overlooked in prisons designed to house men . We must not forget this vulnerable and hidden cohort of women. Molly Skerker et al. explore the challenges for pregnant women in prisons worldwide.

This article, published by the Institute for Healthcare Improvement, discusses some of the key patient safety issues in the Danish Prison and Probation Service. The author, Christian Vestergaard, a Medical Advisor with the Danish Society for Patient Safety, highlights differences in approaches to patient safety in prisons compared to other areas of healthcare provision in Denmark and stresses the need for action to improve the safety of care in these settings.

The Crown Prosecution Service (CPS) prosecutes criminal cases that have been investigated by the police and other investigative organisations in England and Wales. The CPS is independent and make their decisions independently of the police and government. This web page includes information on: What is a 'death in custody'? Death following contact with the Police Handling of death in custody cases Who investigates deaths in custody? Who advises on charge and prosecutes death in custody cases? Self-defence and Reasonable Force CPS contact with families The Coroner The Inquest.