The long wait: A thematic review of delays in the transfer of mentally unwell prisoners.

When we think of prisons, we assume they are full of those who have committed crimes for which they are being held accountable or those awaiting a court judgement. Yet they remain a legal ‘place of safety’ which can be used when there is no suitable provision in the community. Our prisons continue to hold a number of very seriously mentally unwell men and women.

All too often, I meet prison officers and health professionals struggling to care for these patients. To be clear, we are not talking about those who have the will and capacity to accept support during a mental health crisis or when they are at risk of self-harm. These include people whose psychosis or paranoid delusions can make them so violent they are held in isolation in the segregation unit, requiring multiple officers to unlock them just to deliver their meals. Or those so driven to harming themselves they have repeatedly blocked their own airways with bedding, removed teeth or maimed themselves to the point of exposing their own intestines, frequently causing life-changing injuries.

Treatment, assessment and care for patients under the Mental Health Act (MHA) cannot legally be provided in prisons. Early treatment for mental health disorders is vital and delays in accessing care that cannot be provided in prison can cause irreversible harm. Given this, the current strain on prison places, and the psychological and physical challenge for prison officers and nurses attempting to care for such unwell people, their prompt removal from prison to secure hospitals should be a priority. But it is not. Instead, people linger in prison for weeks, often months and even, in the worst cases, for more than a year waiting for their transfer to be completed.

In 2022–23, over three-quarters of our inspection reports commented on the delays in transferring these seriously unwell men and women from prison to secure mental health beds where they can receive the care they so desperately need and to which they are entitled.

In this review, we focus on the actual wait for these patients rather than just the process: we reveal the extent of these delays, where they occur, and the effect that this is having on those living and working in places of detention. We found many examples where staff assessed, cared, and advocated for their patients. Yet it was evident that, no matter how hard they tried, the ultimate barrier to improving outcomes was the limited access to mental health beds. Of the cases we looked at, fewer than 15% of patients were transferred within 28 days.

We found that access assessments, a key part of the transfer process, were frequently delayed without any recourse and that there was a lack of transparency on how admissions were authorised or rejected and how priority for beds was determined, despite clear commissioning specifications being in place. This was a process-driven pathway constructed to gatekeep beds rather than to optimise patient outcomes.

Prisoners, other prisoners, nurses and prison staff are suffering real harm because of the delays in transferring people to hospital. The level of distress for some of the most unwell people hidden behind the bleak walls of prisons across England and Wales is appalling.

I will always remember the deep shock of walking into a unit in Eastwood Park, where acutely mentally unwell women were being held in appalling conditions with bloodstains on the floor and scratch marks on the walls; evidence of the levels of distress of the women being held there. I was also hugely concerned by the effect trying to care for these highly distressed women was likely to be having on staff – prison officers with little or no training in mental health.

At Low Newton women’s prison in Durham the screams from the inpatient unit where the most mentally unwell women were held were so distressing that other prisoners told us they were put off going for their medical appointments. An experienced and dedicated prison officer told me, with palpable frustration, about his attempts to look after these desperate women without either the training or the resources to support them.

Both of these examples are from women’s prisons, but this is not a problem confined to women. In almost every men’s prison I have set foot in since becoming Chief Inspector I have seen desperately unwell men awaiting transfer to hospital while being held in the bleakest of conditions.

The draft Mental Health Bill 2022 sought to remove the use of prison as a place of safety and to reform the Bail Act to prevent courts from remanding defendants for own protection solely for mental health reasons. The Bill also proposed a statutory time limit of within 28 days to complete transfers under the Mental Health Act from prisons to hospital. However, the Bill was not included in the King’s speech in November 2023, meaning that there will be no legislative reform of the Mental Health Act 1983 in the forthcoming parliamentary session. It is therefore more important than ever to shine a light on this issue.

This report raises a number of concerns which should be addressed to enable a process that ultimately improves outcomes and reduces harm, both for very unwell patients and the staff who care for them.

Fundamental change requires a commitment to placing the patient at the centre, creating an independent and accountable admissions process so that they can access early care and get the help they desperately need.

Charlie Taylor, HM Chief Inspector of Prisons

February 2024