14. MENTALLY DISORDERED PRISONERS

Transcription

1 14. MENTALLY DISORDERED PRISONERS Introduction 14.1 John Boyington's statement at paragraphs 60 to 74 describes the changes which have occurred in the care of prisoners suffering from mental disorder by the implementation of Changing the Outlook: A Strategy for Developing and Modernising Mental Health Services in Prisons (Document 64). (The Department of Health and the Prison Service intend to publish a reviewed and updated strategy later this year.) The joint Prison Health team, comprising the Prison Service and Department of Health, has commissioned the National Institute for Mental Health in England (NIMHE) to deliver a national prison mental health programme. The underlying principle is that people in prison should receive mental health care of the same standard as that provided in the community by the NHS. Significant improvements have already been made to prison mental health services. Key to this has been the investment in mental health in-reach services which are similar to Community Mental Health Teams. Small NHS funded multidisciplinary mental health inreach teams are now operating at 102 establishments and should become available by April 2006 within all establishments where the need for them has been identified. The commitment in the NHS plan that 300 additional staff would be in post by the end of 2004 has been exceeded. There are now 360 mental health in-reach staff in post A wholesale revision of the Prison Service system for the identification and management of prisoners at risk of suicide has been completed, leading to a new concept with a greater emphasis on multidisciplinary team working delivered through robust organisational structures. The new process, ACCT (assessment, care, custody, teamwork), is referred to in more detail in the section on safer prisons: cell sharing Those responsible for implementing the prison mental health programme are working with colleagues developing other key NIMHE programmes to ensure that mainstream service developments for people with mental illness are replicated in prisons. Notable examples include improving services for people from black and minority ethnic groups, addressing the needs of women 125

2 prisoners, service user involvement, and the implementation of the social exclusion report In January 2005 NIMHE published "Offender Mental Health Care Pathways" (document 65) which provides up-to-date, evidence-based guidance for commissioners and providers of mental health services from the point of arrest, through prison, to release into the community. It is being implemented in a staged process by the NIMHE regional development centres and is a key document as NHS primary care trusts assume responsibility for commissioning health services in prisons. It also includes guidance that may be applied by police and probation services in terms of the provision of mental health care from the point of arrest, and on release from prison. A separate publication " Offender Mental Health - A case for change" (document 66) contains the background evidence that led to the production of the Care Pathways. Nature of the prison population: the prevalence of mental disorder 14.5 The delivery of mental health services to the prison population presents a considerable challenge in terms of identification and assessment of risk and management. While the principle is that those in prison should receive care of the same standard as that provided in the community, the prevalence of mental disorder is considerably higher. About 140,000 persons pass through English and Welsh prisons each year. At any one point in time, around 75,000 people are held in 135 prisons in England and there are predictions that this figure will continue to rise. It has been estimated that 90% of prisoners suffer from at least one of five principal categories of mental disorder: psychosis; neurosis; personality disorder; drug dependency; and alcohol dependency. The great majority of them would, if they were living in the community, be most likely to be managed by their GPs within the remit of primary care Offender Mental Health - A case for change addresses the prevalence of mental disorders at pages 7 to 10. In comparison to the general population prisoners show evidence of far more mental health problems. The table reproduced below shows, for example, that sentenced men in prison are

3 times more likely to be diagnosed with psychosis and 63% of female sentenced prisoners have a neurotic disorder. Table: A comparisons of prisoners and the general disorders and associated behaviours population: mental health Characteristic -[General population Prisoners Suffer from two or 5% men 2% women 72% male sentenced more mental prisoners 70% female disorders sentenced prisoners Suffer from three or 1% men 0% women 44% male sentenced more mental prisoners 62% female disorders sentenced prisoners Neurotic disorder 12% men 18% women 40% male sentenced prisoners 63% female sentenced prisoners Psychotic disorder 0.5% men 0.6% 7% male sentenced women prisoners 14% female sentenced prisoners.,i... Pers0nality-dis0rder io.,+v/o!-r:;;,_,... men... J._"/o o_"/o male sentenced... I o i women prisoners 50Yo female i J sentenced prisoners I Drug use in previous 13% men 8% women 66% male sentenced year prisoners 55% female sentenced prisoners(in year before imprisonment) Hazardous 38% men 15% women 63% male sentenced drinking _4 prisoners 39% female sentenced prisoners (in year before imprisonment) 14.7 The prevalence of mental health issues among the prison population, compared to the population at large illustrates the scale of the challenge facing prison mental health services. In addition co-morbidity levels are also high which provides additional challenges in terms of diagnosis and identifying priorities in terms of interventions and treatment. It has been estimated that at any given time there will be over 5,000 people in prison who are suffering from severe and enduring mental illness, although not all of them will be acutely ill. These people would, if they were living in the 127

4 community, be most likely to be referred by their GPs to a specialist mental health NHS Trust for treatment. While a prisoner who has a mental disorder is not necessarily dangerous on that account alone, the degree of risk the prisoner may pose to self and others may increase the longer that disorder remains untreated. Risk management issues 14.8 The high prevalence of mental disorder raises a number of risk management issues in relation to the significant majority of the prison population which the Prison Service is required to address, particularly institutional risk in terms of both the risk of self harm and of violence towards other prisoners and staff, and the risk of re-offending and aims of rehabilitation. This calls for both generic approaches applying across the board to identification of risk and management of offenders and specific interventions geared to the needs of the individual and/or levels of risk. Some are specifically mental health interventions. Others are not but are relevant to any consideration of the identification and management of those with some form of mental disorder. The following paragraphs give a brief outline of the range of approaches and interventions before addressing some of them in greater detail. There is some cross over with the section on mentally disordered prisoners Risk assessments are conducted at various points in relation to the management of offenders: at reception in terms of first reception health screening and the cell sharing risk assessment; in the context of sentence planning through the Offender Assessment System (OASys); mental health assessments by the mental health in-reach teams on referral from health care team following initial mental health assessment; and in the more severe cases admission to the health care centre for comprehensive mental health assessment and possible transfer to the NHS outside prison. In addition, risk assessments may be conducted for possible transfer to Dangerous and Severe Personality Disorder (DSPD) services or a Close Supervision Centre (CSC) unit, or to assess suitability for various offending behaviour treatment programmes This gives rise to a number of risk management strategies available depending upon the scale and nature of the risk. The quality of regime - the 128

5 availability of purposeful activity, benefits all prisoners and contributes to the management of risk. Sentence planning, which is aimed at addressing the likelihood of re-offending, makes a vital contribution to the management of risk both in prison and upon release. Specific Interventions may include drug treatment services, Offending Behaviour Programmes, or referral to one of the Therapeutic Communities. The Violence Reduction strategy aimed at addressing the risk of violence towards others and the work of ACCT teams in managing those at risk of self harm are dealt with elsewhere (in the sections on safer prisons: violence reduction and safer prisons: cell sharing respectively). Other risk management strategies available include segregation in the short term or referral to a DSPD unit or Close Supervision Centre. The work of mental health in reach teams or transfer to hospital are the other specific mental health interventions which are considered in detail below. Identifying mentally disordered prisoners The focus of the Inquiry's questions on this topic is the time, qualifications and experience of medical staff to assess a prisoner's mental state. It is important to stress that the approach to identifying and managing mental disorder in prisons, as described in the Care Pathways document, is a multidisciplinary one with different levels and types of intervention from both medical and non-medical staff. This is covered in detail below. While establishments are investing in the system there described, individual establishments will be approaching it from differing starting points and may therefore have some elements in place but not others. It is also important to acknowledge that the number of prisoners with mental health problems, as described above, puts considerable pressure on the available resources notwithstanding the scale of investment in in-reach services as described in John Boyington's statement at paragraph As is apparent from the Care Pathways document, the first stage in identifying prisoners with mental health problems is the First Reception Health Screen. Where mental health screening triggers are present in answer to the mental health screen, a referral is made to a mental health professional (which could be a nurse, doctor, occupational therapist, psychologist or social worker) on the health care team for an assessment. Where appropriate a 129

6 referral will be made by that person to the in-reach team who will then conduct a mental health assessment of need and risk. A GP in primary care can make direct referral to a psychiatrist where appropriate. The in-reach team can make referrals to general and/or forensic psychiatrists where there are particular concerns about a prisoner. Depending upon the severity of mental health problem following assessment the prisoner may be referred back to primary care or health care with advice and support to develop a care plan, or remain with the in-reach team for secondary care through a multidisciplinary care management process. Where the prisoner's mental health level of risk to self or others cannot be managed on the wing, the inreach team will refer to admission to the Health Care Centre as an inpatient In the more severe cases, a referral may be made for admission to the health care centre for 24 hour support, supervision, observation and short-term intensive care to stabilise prisoners with acute and severe psychiatric crisis or prisoners suffering from life-threatening self-harm, drug overdoses or suicide attempts, or those in acute crisis due to co-existing complex morbidity problems. In some cases it may be necessary to refer to the NHS outside prison for specialised acute inpatient care. Qualifications and Training In-reach teams are primarily led by Registered Mental Nurses (RMNs) but may include sessional input from clinical psychologists, occupational therapy, psychiatrists and other therapeutic disciplines such as art, drama, music therapists. The composition of in-reach teams will depend on the amount of funding allocated for their provision and the assessed needs of the client population at any Particular establishment As explained with regard to Health Care Centres, training was given on the First Reception Health Screen to health care staff who undertake reception screening. The training for trainers programme has ensured that there are staff at each establishment able to train new staff as needed. All staff undertaking reception screening will have received training and there are staff at each establishment who are trained to deliver this training. Thereafter, if the mental health screen triggers are present in answer to the mental health screen a referral is made to a mental health nurse who will have the required 130

7 professional training to enable them to identify mental disorder. The aim of inreach teams is to provide a multi-disciplinary specialist assessment and treatment service similar to the Community Mental Health Treatment model in the community and they therefore offer a range of expertise. Mental Health Awareness Training for Discipline Staff More generally, it is recognised that it is important that all prison officers should receive mental health awareness training. As covered in John Boyington's statement at paragraph 74, following a study into mental health in 2000 where prison officers were asked about their attitudes to mental health the basic training has been improved as well as the training of establishment staff in relation to mental health awareness. The mental health awareness training for prison officers is being implemented as a long-term strategy to raise the effectiveness of discipline staff in understanding, engaging and getting support in the care and management of prisoners with mental problems. Following a pilot training package at 15 establishments to support the development of wing-based mental health liaison and ACCT assessor roles, a mental health awareness-training package has been developed and produced specifically for Prison Service staff. A comprehensive support pack, comprising a training manual, course participant manual, evaluation report, training video and CD ROM, have been produced and circulated to all regional prison mental health leads. The implementation of this programme will be determined by the regional prison mental health forums. The programme is targeted towards meeting the training needs of prison discipline staff, particularly those involved in escort and reception duties. It aims to give all staff a basic understanding of mental health and of the mental disorders that are commonly found in the prison setting. In January 2005 a Strategy for Mental Health Awareness Training and Assessment Care in Custody Teamwork, agreed by Prison Health, Safer Custody Group and the Prison Service's Training and Development Group, was published (document 67). This sets out an overview of the modules of training for the Assessment Care in Custody Training (ACCT) course and Mental Health Awareness Training (MHAT). There are four tiers of training A pilot training programme in personality disorder awareness, in the form of a web-based package, is planned for prison staff in North West England and 131

8 London in collaboration with NIMHE. It will be based on the NIMHE Personality Disorder Capabilities Framework: Breaking the Cycle of Rejection. This aims to provide students with an explanatory framework for personality disorder, to challenge negative attitudes, introduce techniques for effective self-management and outline the capabilities for effective ways of working with people with personality disorder. It also address team functioning, capabilities, management and leadership issues. Transfer to hospital for inpatient treatment Many prisoners, particularly those in the acute stage of a mental illness, are transferred to hospital within a reasonable timescale. It is accepted, however, that problems of apparently excessive delay can still occur in some individual cases. Although considerable efforts have been made to reduce such delays, the Prison Service estimates that any one time there will be around 40 or so prisoners who will have been waiting longer than three months for a hospital place following acceptance by the NHS. Tighter regular monitoring has already been introduced to identify any prisoners who have been waiting unacceptably long periods for transfer to hospital. A protocol issued in 2003 set out what must be done when a prisoner has been waiting for a hospital place for more than three months following acceptance by the NHS. As indicated by the rise in the number of transfers in 2003, both appear to have brought about an improvement. In prisoners were transferred as restricted patients under section 47 and 48 of the Mental Health Act 1983, a rise of 12% on the 2002 figure of 644. It is accepted that there remains a lack of clarity around the arrangements for transferring prisoners with mental health problems to hospital. The Prison Service, Prison Health, the National Institute for Mental Health in England (NIHME), and the commissioners and providers of NHS hospital services are now working collaboratively on a two year project (commenced April 2005) to establish a national waiting time limit for transfers between custodial settings and hospitals that is equivalent to the waiting time for referrals between mainstream NHS providers and hospital and to ensure that it is maintained for all prisoners requiring transfer, to develop referral guidelines and care pathways both to and from prison and hospital settings and to monitor national compliance. 132

9 Assessing Risks By reason of their training and experience, mental health in-reach teams can reasonably be expected to be competent to assess the risk an individual poses to himself or others as a direct result of a mental illness (people with mental health problems are more likely to harm themselves than other people). There is no formal risk assessment tool in use. Where there are particular concerns about an individual prisoner the in-reach team will have open to it avenues of referral to general and/or forensic psychiatrists. Each NHS Trust will have its own risk assessment/management policies and will design and train its workforce to ensure that they are delivered Risk assessment tools which are relevant to identifying and managing dangerous prisoners are set out below. The context in which these risk assessments are conducted is sentence planning and specifically with regard to interventions to address the needs of dangerous offenders to reduce the risk of re-offending and aid resettlement. This subject is covered specifically in the section on risk assessments. It is important to set the use of risk assessment tools in context. The science of risk assessment is in a relatively early stage of development. For example the use of static risk factors has demonstrated reasonable levels of predicative accuracy in terms of reconviction. The understanding and use of dynamic (changeable) risk factors is the current focus of development in this field. Dynamic risk factors may prove to be particularly valuable due to their implied potential to identify effective intervention. The successful use of risk assessments will always be dependent in a prison context upon the time, resource and skills pressures The OASys risk assessment tool is described in Phil Wheatley's second statement at paragraphs 6.43 to 6.52 and in greater detail in the section on risk assessments. OASys cannot provide in-depth assessment of all aspects of risk. It is designed to trigger further assessments in some areas, for example, of sex offenders; violent offenders; basic skills, drugs and alcohol; mental health and dangerous and severe personality disorder; racially motivated offending and domestic violence. Specialist assessment tools in relation to dangerous offenders are set out below. A number of Prison Service forensic psychologists have training in the use of these tools. 133

10 14.22 Risk Matrix 2000, the specialist assessment for sex offenders which is triggered by OASys, is an evidence-based actuarial risk assessment that has also been approved by the Association of Chief Police Officers for use by the Police Service within England and Wales. Risk Matrix 2000 uses the same classifications of risk of serious harm as OASys and where there is any disparity between the two assessment tools in respect of the likelihood of reconviction, the Risk Matrix 2000 risk level should take precedence For violent offenders there are a number of actuarial and clinical structured risk assessment tools that could be used to identify level and type of risk the individual poses. These include the HCR-20 and Violence Risk Scale, which are administered by qualified and trained staff, for example by psychologists assessing prisoners in Close Supervision Centres. Both of these tools include static risk scales. One advantage of using these tools is that they provide an indication of treatment need as well as risk and can be used to inform treatment pathways and risk management strategies The presence of high levels of psychopathic traits is also linked to risk. The standard tool for assessing psychopathy is the Psychopathy Checklist- Revised (PCL-R). A high Score on the PCL-R is a strong predictor of violence risk and is also associated with general offending and sexual offending, especially when combined with sexual deviance. The PCL-R provides useful information for risk management and likely response to interventions, but does not provide information on what type of risk the individual poses and what targets to treat. It is therefore part of a more complex process of assessing an individual's risk factors and treatment related needs within a very comprehensive assessment. It helps ensure that offenders receive the right treatment for them and avoids them being referred to treatment which may be inappropriate or ineffective There are significant resource implications in relation to the use of the PCL. A PCL-R assessment process varies but is likely to take a minimum of 1-2 days. Psychologists trained to conduct a PCL-R are in limited supply. 134

11 The Mana.qement of Prisoners with Personality Disorder who are assessed as potentially dan.qerous The section on risk assessments sets out the Prison Service's Dangerous Offender Strategy and work currently under way in NOMS to develop a high risk offender's strategy Each establishment has a Violence Reduction Strategy in place to manage the risks that prisoners may pose to staff or other prisoners. This is described in Phil Wheatley's second statement at paragraphs 6.39 to 6.42 and in greater detail in the section on safer prisons: violence reduction Dangerous offenders with mental disorder can also pose threats to themselves in terms of the risk of suicide or self-harm. Measures to address suicide prevention and self-harm reduction are covered at the section on safer prisons: cell sharing The following addresses the range of interventions and programmes arising from the specific assessments of risk which relate to the management of violent or potentially violent prisoners. Some are specifically mental health interventions. Others are interventions to which violent offenders with personality disorder will be subject. Offending Behaviour programmes Offending behaviour programmes are a key aspect of the Prison Service's approach to addressing risk. A range of accredited sex offender treatment programmes are offered according to risk and need. The accredited Cognitive Self-change Programme is designed for high-risk violent offenders. For those with anger and emotion management needs there is the accredited CALM programme In order for treatment to be successful, participants must be able to engage meaningfully in the programme, be motivated, and able to bring about and sustain behavioural change. In addition to meeting the risk offenders pose, programmes must be designed to accommodate and meet their responsivity 135

12 needs. Some groups of offenders present specific responsivity needs which are not met by programmes designed for general offenders All the offending behaviour programmes are carefully designed and have clear criteria to ensure that they address the needs of those who are referred to them. These referral and assessment criteria have been evaluated and supported by independent international experts on the CSAP. Each programme has an assessment process to ensure the programme is right for the individual, (and to ensure that this limited resource is given to those offenders who are most likely to benefit). These involve a number of assessments. Programmes for high risk offenders which have not been designed to accommodate a high level of psychopathic traits are unlikely to be sufficiently responsive to the needs of highly psychopathic offenders. These include high intensity programmes such as the core and extended sex offender programmes, and CSCP violence programme. In each case the individual will receive a full assessment looking at a range of factors to determine whether a programme targets their risk factors and is able to accommodate their responsivity needs (for example low IQ, literacy needs, severe mental illness, high levels of psychopathy). Enhanced guidance on assessing the suitability of such interventions for an offender with high levels of psychopathy is being issued to relevant programme staff in June 2005 (document 68) If an existing offending behaviour programme is not able to sufficiently meet the needs of an offender, there are other options around risk management (for example through MAPPA - see section on risk assessments) and referral to other appropriately designed treatment within DSPD such as Chromis Therefore, the PCL-R is part of a more complex process of establishing individuals' risk factors and treatment related needs and is located within a very comprehensive assessment. It helps staff ensure that offenders receive the right treatment for them, and avoids them being referred to treatment which may be inappropriate or ineffective. 136

13 Drug Treatment Services Prisons offer drug-misusing offenders a comprehensive range of interventions to address low, moderate and severe drug-misuse needs. These comprise: Clinical Interventions (detoxification and maintenanceprescribing programmes); CARAT (Counselling, Assessment, Referral, Advice & Through-care) services; and Drug rehabilitation programmes. Additionally, prisons encourage all offenders to sign Voluntary Drug Testing (VDT) compacts - as an indication of their commitment to stay drug-free. Offenders signed up to VDT are liable to a minimum 18 drug tests per year In 2003/04 there were around 58,000 clinical interventions; 55,000 CARAT initial assessments; 5,000 entrants to drug rehabilitation programmes (with 2,500 completions); and 33,000 prisoners signed up to VDT. Therapeutic Communities Democratic Therapeutic Communities (TCs) are offered within the Prison Service as an intervention for medium to high-risk offenders, for offences ranging from violence (including robbery) and sexual crimes, to arson and crimes of dishonesty. TCs offer a long-term residential treatment programme where emotional and psychological needs are addressed alongside risk factors relating to offending behaviour. Offenders who may be unsuitable for other offending behaviour programmes or who are deemed unsuitable for attendance on these programmes but who still present as high need may benefit from the TC treatment programme Grendon A Wing was accredited in Subsequently a core model for Prison Service TCs was provisionally accredited by the CSAP in October 2003 and was fully accredited in March PSO 2400 published in December 2004 outlines the strategic development and performance management of TCs and provides information about the provision of TC places within the prison estate. Currently there are TCs in Grendon, Dovegate, Gartree, Aylesbury, Blundeston and Send providing PC places for 500 prisoners. 137

14 14.39 Following accreditation, a much wider programme of evaluation and research is planned throughout all prison based TCs Prisoners with personality disorders who are assessed as dangerous or potentially dangerous who cannot be managed on normal location may be held in segregation units or referred to a CSC unit or to the DSPD programme. The Dan.qerous and Severe Personality Disorder Proqramme Dangerous offenders whose offending is linked to severe forms of personality disorder present complex and difficult challenges across criminal justice and health systems, in terms of public protection, meeting their mental health and other needs, and for resettlement. The Government estimates that there are some persons already in custody (mostly in high secure prisons) who meet the DSPD criteria of high risk and severe personality disorder. It is anticipated that a significant proportion of those who would be caught by the public protection provisions of the CJ Act 2003 will also fall into this group The Dangerous Severe Personality Disorder (DSPD) Programme is linked to a 2001 Manifesto commitment and NHS Plan undertakings. Its aims are to enhance protection of the public and improve mental health outcomes by understanding better: a) How to identify, assess and treat those who are dangerous and severely personality disordered. b) The nature and challenges of treatments and service delivery involving multi-disciplinary teams working across agencies c) The extent to which treatment might reduce (or manage better) the risks of re-offending and how best to move on those offenders who have benefited from the programme, as well as those who have not. d) To strengthen the clinical, service delivery and policy evidence base in this area, informing the options for future services, benefits. and the costs and To achieve these aims the Programme is working at the leading edge of what is known in clinical terms, in the organisation of services and cross-agency 138

15 work, commissioning evaluation and research. The DSPD Programme is very much work in progress. It is a set of pilot developments aimed at elucidating the way forward in terms of management and treatment of this group of offenders, and, drawing on its lessons, more generally for those offenders with personality disorders. It is not meant primarily as a way to manage institutional risks - though clearly the high staffing ratios and actively supportive regimes mean that they can do this well. Many dangerous offenders are not difficult to manage institutionally, indeed some e.g. sex offenders, are seen as vulnerable in the prison setting. The main focus is to address the risk of re-offending more broadly, and for some this will mean in the community The development of DSPD pilot services is guided through a series of Planning and Delivery guides. The high secure services guide (document 69) sets out the framework within which services are intended to develop in the short to medium term. It includes guidance about criteria, the referral process, clinical services, planning and evaluation. Other guides (on medium secure and community NHS pilot services and on women) are under development. The main components of the programme are set out below Firstly, there is a high secure provision of 300+ places to pilot assessment and treatment services. A planning and delivery guide for high secure service development was issued in June 2004, to help the development of these services. The capacity target is being met by developing Units at i. HMP Frankland, 80 places: The unit has been open since May 2004 and has a current occupancy of 58 prisoners ii. HMP Whitemoor, 84 places: The unit has been open since 2002 and has a current occupancy of 55 prisoners iii. Rampton high secure hospital, 70 places: This unit opened in march 2004 and has a current occupancy of 23 patients iv. Broadmoor high secure hospital, 70 places. The main unit will open in July 2005, when construction will have been completed. A small ward-based development of 10 beds has 139

16 been in place for 2 years, and is fully occupied DSPD Services are monitoring the development and use of the units. In aggregate terms over 140 prisoner/patients are currently in the units, at various stages of assessment or treatment. In the last quarter (January - March) 77 cases were referred to the high secure units overall, the vast majority with a history of violent or sexual offences, or both. Rampton and Broadmoor are currently engaged in recruitment drives to enable them to meet their projected staffing levels. DSPD services are aiming for the occupancy across the 4 high secure units to have reached at least 250 by March 2006, though this will depend on recruitment targets over the next 12 months being met Secondly, the programme also includes: five other pilot projects in appropriate NHS specialist services at medium security and in the community, for offenders who have made progress and whose risk can safely be managed in that context. Together these will provide a total capacity of 71 places at medium security and community hostels by end of May. The aggregate occupancy at the end of March was 23. a pilot specialist in-reach service for up to twelve women prisoners who are dangerous as a result of personality disorder, as well as broader assessment and advisory service to prisons. This is being based at HMP Low Newton. A dedicated therapy space in the prison is currently under construction and should be available from July Thirdly, the evaluation of the Programme will look at a range of issues, including deliverability of assessments and therapies, and what lessons will need to be drawn about the future shape of services for this group of offenders. Both HO and DH are involved and the evaluation is being commissioned jointly. DSPD Services expect to be able to commission an external academic team in June or July. Programme priorities over the next 18 months will be to complete the development of the pilot services and to have started evaluation of those aspects of service delivery for which it is 140

17 sensible to expect short-term answers. This will help in reaching decisions about the future shape and direction of the DSPD Programme, in the light of the emerging evidence of delivery experience and the potential impact of the interventions in reducing risk Fourthly, other aspects of the programme are looking at developing progression pathways for those who have been assessed or treated in DSPD units, and strengthening guidance for the MAPPA. The referral to a DSPD unit will, in the majority of cases, be initiated by the prison currently holding the prisoner. There is comprehensive guidance about the referral information needed. The referring establishment (as well as the prisoner) will get feedback about the decisions taken (i.e. not to accept, admit for assessment, admit for treatment) and depending on how far down the process a particular case has reached, the feedback would be more detailed. For those assessed & not admitted, and those admitted but who may be leaving, feedback should include advice about the level of risk and a forward looking management/health plan of the person concerned. Depending on the circumstances a range of options would be explored, including e) Transfer to another treatment programme in the prison service, e.g. therapeutic communities, other offender behaviour programmes f) Transfer to secure hospital, whether to a hospital based DSPD unit or to some other hospital place. In such circumstances the case will need to meet the criteria of mental health legislation g) To a prison health centre, as a first step in a broader management plan h) Management on ordinary location with support from the health centre or the mental health in-reach team. i) To identified places within prisons, which would have added support from healthcare and other professionals, as part of managed progression pathways out of high security. These are at the planning stage. 141

18 j) For those whose release is imminent and whose risk will continue to be managed in the community, linking in with the appropriate MAPPA within the locality in which the prisoner is to be released so that the supervision and aftercare package is informed about the risks and the work that may already have been done about the needs of the offender. The mana.qement of prisoners with personality disorders who are not admitted to the DSPD Proqramme The following sections deal with two other options available in relation to the management of dangerous prisoners who cannot be managed on normal location. The Use of Segregation Segregation as one of the arrangements for holding dangerous prisoners is described in Phil Wheatley's second statement at paragraphs 9.11 to 9.13, and 9.17 to The following updates and describes in more detail the policy with regard to segregation and changes made in November 2003 with regard to mental health screening for those in segregation. The focus of these developments has been the risk of suicide and self-harm PSO 1700 was revised primarily in response to the concerns raised in the ECHR judgement in the case of Keenan, a prisoner who had committed suicide. Much of the judgment criticised the medical care that Mark Keenan had received while in segregation and the adjudication process that had led to him being awarded additional days without proper consideration of his mental condition and fitness for punishment The prison staff who work in the segregation unit must be selected on the basis of their competence to deal with difficult situations and their ability to form constructive relationships with prisoners. They will normally be appointed for a maximum period of 2 years. They must be competent (which normally means 'trained in') in Suicide Prevention and Mental Health Awareness. 142

19 14.56 As previously described the Safety Algorithm is a mental health screening document which must be completed by a nurse or doctor on all prisoners placed in segregation. The target time for completion is two hours. The healthcare team produce a recommendation stating whether they think there are medical reasons to advise against segregation at this time. It is expected that approximately 5-10% of prisoners in high security and local prisons will be identified by the algorithm as either needing extra care while being held in segregation or not being suitable to be segregated at all. The duty governor will decide how to proceed after looking at the algorithm recommendation and talking to medical and segregation staff. Under current Prison Rules, if a doctor recommends that a prisoner must leave segregation, the governor must give effect to this instruction The Prison Rules are, however, expected to be changed later this year to reflect the Prison Service's preferred policy, which is that in difficult cases, and where the healthcare team advises that there are medical reasons against segregation, the way forward should be decided at a case conference. This will aim to discuss the individual prisoner and the most appropriate management of that prisoner, given the circumstances. The governor, relevant prison staff, nursing staff, doctor and outside psychiatrist will be asked to attend PSO 1700 stipulates that copies of all case conference review notes must be sent to Security Policy Unit. These notes are reviewed quarterly with the assistance of the Prison Health team and guidance notes published on the website. The guidance notes are aimed at assisting prisons in the management of this small number of prisoners who pose significant difficulties for both medical and disciplinary reasons. Close Supervision Centres CSC units opened in February 1998, replacing Special Units. They are located in high security prisons. The aim of CSCs is to enable dangerous, disturbed, and disruptive prisoners to develop a settled and acceptable pattern of behaviour. CSCs are administered under a national management strategy. The role of the CSC is to remove the most seriously disruptive prisoners from main location prisons and contain them instead in small, 143

20 highly-supervised units. CSC prisoners often have a range of complex and diverse psychological, psychiatric, and security needs. CSCs provide the opportunity for individuals to address their disruptive behaviour, aiming to stabilise prisoners and prepare them for a return to main location prisons. CSCs also provide long-term containment of those who continue to pose a serious threat Total CSC Capacity is currently 55 (45 in core units and 10 designated by the Deputy Director General for locating Rule 46 (CSC) prisoners in High Security Prison Segregation Units CSC's operate under Prison rule 46 which states: - "Where it appears desirable, for the maintenance of good order or discipline or to ensure the safety of officers, prisoners or any other person, that a prisoner should not associate with other prisoners, either generally or for particular purposes, the Secretary of State may direct the prisoner's removal from association accordingly and his placement in a close supervision centre of a prison. A direction given under paragraph (1) shall be for a period not exceeding one month, but may be renewed from time to time for a like period, and shall continue to apply notwithstanding to another. any transfer of a prisoner from one prison The Secretary of State may direct that such a prisoner as aforesaid shall resume association with other prisoners, either within a close supervision centre or elsewhere. In exercising any discretion under this rule, the Secretary of State shall take account of any relevant medical considerations that are known to him. A close supervision centre is any cell or other part of a prison designated by the Secretary of State for holding prisoners who are subject to a direction given under paragraph (1)." 144

21 14.62 CSC Selection Committee (CSCSC) makes selection decisions in accordance with the selection criteria, based on a thorough assessment process. Guidance on this is provided in the CSC Referral Manual (document 70). Selection into the system does not require prisoner consent, although consent will be sought where possible. The referral criteria for CSCs is contained in I.G. 28/93 (document 71)(see in particular paragraph 24). Prisoners who meet that criteria are causing day-to-day management, safety, and control problems for those who detain him and/or for those with whom he resides. An individual who is suitable for placement in a CSC will be demonstrating or threatening to demonstrate behaviours that are dangerous to others (and additionally in some circumstances to himself), and is no longer considered safe to be managed on normal location or in a segregation environment. Previously, he will have demonstrated violence and/or control problems and has failed to respond to alternative methods of control such as segregation There are 6 key stages in the CSC assessment process, described in detail in the CSC Referral Manual. An overview of those stages is in Chapter 2. Once a case has been accepted by the CSC Selection Committee a series of reports are commissioned. These reports are designed to provide multidisciplinary risk assessments, including mental health needs and will include reports from a forensic psychiatrist and forensic psychologist With regard to prisoners with severe personality disorder, it is possible that an individual will meet the criteria for both the DSPD and CSC if his PD is linked to an offending pattern making him suitable for DSPD referral, while also presenting a control problem in his current environment. In those circumstances the prisoner must be referred initially to the CSC system. Once the prisoner is no longer causing daily control problems and can be managed on normal location, a referral to the DSPD service can be made. More details about the assessment process and considerations where a prisoner has a personality disorder are in Chapter 5 at paragraph 5.3 of the Referral Manual The Care and Management Plan will reflect a multi-disciplinary approach to managing and reducing violent and/or disruptive behaviour - see chapter 8 of the Referral Manual. There are no time constraints regarding a prisoner's placement in the CSC and plans are therefore based on ongoing assessments, which are used to monitor individual progress and risk 145

22 reduction. These comprise a combination of daily behaviour rating sheets and observation books completed by wing staff, an on-going assessment of risk and individual interventions by psychologists, and inputs from the other service providers such as education, PE, health care and mental health teams There is currently a Violence Reduction Programme that is being piloted in the CSC. The Programme is designed to reduce institutional violence; to deliver individual treatment plans, to increase mental stability and to prepare prisoners to move to alternative locations. The communication of concerns about risk by medical staff to discipline staff Communication of concerns about the risks of personality disordered offenders on ordinary location is managed through the case conference process. By way of example, Practice Guidance Notes on Case Conferencing at Feltham are supplied. (document 72). Practice will vary between establishments. Representation at these meetings may include security, healthcare, safer custody, the probation department, chaplaincy (YOT team in the case of juveniles) and duty governor but in some establishments there may be poor attendance from residential staff on wings because it can be difficult for them to be freed up from the residential wing duties to attend. Where this is a problem, communication may be through the history sheet entries or a written case summary rather than direct verbal communication and discussion. Case conferences are minuted and there will be an action/management plan. Successful management of such offenders is achieved through good communication and joint working at all levels. 146