Shaw, Jenny, McFadzean, Joy, Senior, Jane, Wainwright, Verity, Ibrahim, Saied, Avery, Anthony, Carson-Stevens, Andrew  ORCID: https://orcid.org/0000-0002-7580-7699, Ashcroft, Darren, Buck, Deborah, Butt, Noor, Campbell, Stephen, Flynn, Sandra, Hendricks, Caroline, Hewson, Tom, Keers, Richard, Millar, Tim, Millington, Tracy, Muller, Claire, Panagioti, Maria, Sanders, Caroline, Thompson, Ellie, Davies, Kate, Edwards, Adrian ORCID: https://orcid.org/0000-0002-6228-4446, Gwyn, Sioned, Hellard, Stuart, Purchase, Thomas ORCID: https://orcid.org/0000-0002-4504-2111, Bell, Brian, Hussain, Basharat, Jordan, Melanie, Walter, Florian and Waring, Justin
2024.
Understanding the scale and nature of avoidable harm in prison healthcare.
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Abstract
Background Around 1 in 20 patients experience avoidable healthcare-associated harm worldwide. Despite longstanding concerns, there are insufficient data available about the safety of healthcare for prisoners. Prison is a challenging environment to provide healthcare, due to the complex needs of the population, often presenting with multiple health morbidities, substance use and mental health conditions. Older adults are the fastest growing group in prisons in England and Wales, with an associated high demand for health and social care. Examining healthcare records to assess care quality and safety, known as case-note review, can inform epidemiological estimates of healthcare-associated harm, and reviewing the data within medical records provides an opportunity to assess the safety of all care provided, not just that provided by the prison healthcare team alone. Aim To explore the scale and nature of avoidable healthcare-associated harm for prisoners receiving healthcare in England, from case-note review and qualitative enquiry. Objectives • Estimate the incidence of avoidable healthcare-associated harm for prisoners. • Quantify, describe and classify the nature and severity of avoidable patient harm. • Identify contributory factors that, if addressed, could reduce the incidence of avoidable harm in prisons. Design and methods A large retrospective cross-sectional study involving case-note review of patient healthcare records in 18 prisons in England was undertaken. Prisons were purposively sampled for maximum variation of characteristics based on prison category (open, local, training, high security and female), type (publicly and privately run), healthcare provider (NHS or private provider) and population size. The incidence of avoidable harm was estimated and expressed as ‘per 100 000 patients per year.’ To prepare for the case-note review, we carried out a sequential mixed-method study incorporating analysis of serious incident investigation reports, stakeholder consensus building workshops and validation using patient safety incident report data to better understand avoidable harm within the context of prisons and to propose a scale of avoidability. We examined cases of avoidable harm within records that were characterised in terms of the type of patient safety incident(s) that had occurred, contributory factor(s), outcome(s), and the degree(s) of harm caused. Univariable and multivariable analyses were subsequently conducted to identify factors associated with avoidable harm. The primary outcome was the rate of patient harm judged to be at least probably avoidable. The secondary outcome was the rate of patient harm judged at least possibly avoidable. To contextualise our findings, we engaged with stakeholders and carried out expert workshops and conducted a full qualitative examination into the barriers and facilitators to the safe delivery of prison healthcare through the interviewing of service users and a range of professionals working within prisons. Findings Phase 1a defined healthcare-associated avoidable harm within prisons using a two-tier approach which acknowledged the complexities/nuance of secure environments, and how the prison regime may impact on healthcare delivery, with both community care (Tier 1) and prison regime (Tier 2) considerations. Phase 1b characterised the nature of patient safety incident reports from prisons, to signal potential healthcare- associated harm. Phase 2 involved a case-note review of 7147 patient records from 18 prisons across England. There were 247 cases of avoidable harm; most cases were identified from the enhanced sample (233, 94.3%) whilst a small number were from the out-sample (14, 5.7%). The incidence of avoidable harm derived from the enhanced sample was 2114.3 (95% CI 1851.5-2404.0) per 100 000 patient years. Phase 3 highlighted the impact of examples of avoidable harm as reported by staff and people residing in prison, including medication mismanagement and healthcare access difficulties. There were also shared experiences of further challenges to providing safe care due to staffing levels, communication difficulties between teams, and at transition periods (i.e., on entry to prison, transfer between prisons, or on release). Limitations This work focused on prisons and safety reports within England only, and whilst this was a large sample, there may be limits on the transferability of findings to care delivery in devolved nations. This is especially pertinent with regards to the commissioning of, and funding distribution for, healthcare, which may not be fully comparable elsewhere within the United Kingdom (UK). It was also recognised that the quality of both incident reports and medical records documentation was variable, and where data were missing, incomplete or unclear, this potentially impacted on the conclusions drawn from these data sets. Conclusions Prison healthcare is inherently less safe when compared with other healthcare settings such as community primary care. Overall, secure environments are a challenging setting to deliver care and equitable outcomes for patients, and there is clear need for government policy to prioritise safer healthcare in prisons, and for strategic action plans that commit sufficient resource and new ways of working that will deliver it to address some of the common causes of avoidable harm.
| Item Type: | Report (Project Report) |
|---|---|
| Date Type: | Publication |
| Status: | Published |
| Schools: | Schools > Medicine |
| Additional Information: | National Institute for Health and Care Research (NIHR) Policy Research Programme Project Ref: PR-R20-0318-21001 |
| Related URLs: | |
| Date of First Compliant Deposit: | 24 July 2026 |
| Last Modified: | 24 Jul 2026 13:54 |
| URI: | https://orca.cardiff.ac.uk/id/eprint/188448 |
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