On Saturday August 21 - the same day that John Leadley was stabbed in the face - there was another prisoner on the segregation unit who was causing trouble. He had been moved there from B wing, where he had been cutting himself, and now he was standing on the water pipes of his cell with a ligature around his neck, threatening to hang himself. A fortnight earlier, a prisoner had succeeded in committing suicide in the seg, so the senior officer there was in no doubt about what he wanted: this man had to be transferred immediately to the prison's healthcare centre, where there are 17 cells for acutely ill prisoners. He called the centre, and one of the doctors came down.
To the senior officer's horror, the doctor refused to take the prisoner. He said the man was suffering from a personality disorder, which was not treatable, and that this behaviour was simply a self-harming gesture. The senior officer became agitated, reminding the doctor that two weeks earlier, they had cut down a body which had then laid in the cell all day while the investigators did their work: "I'm not going to engage in semantics with you. Suppose it happens again. You just can't take the chance." The doctor stood his ground. The senior officer reluctantly backed down but told the doctor: "If this goes wrong, I guarantee you I will stand up in coroner's court and point the finger at you." Then he recorded all that had happened in the seg's observations book.
In the event, the man did not hang himself. The friction passed. But the problem remains. Just like the officers in the seg, the staff in the healthcare centre see themselves struggling to deal with an impossible problem. Apart from the shortage of specialist psychiatric help, the prison has 12 unfilled vacancies for general nurses, leaving only 28 to cover the prison, day and night, for all forms of illness. Sometimes, they try to fill some of the gaps with agency nurses, but they are expensive and can wait up to a month for security clearance. They have only 17 in-patient beds for the whole prison. And, running through all this, they are medical staff working in a prison which has different priorities and understandings and even language.
Are these men prisoners or patients? Who should win the argument if prison officers want to search a man's cell but health staff say it will aggravate his mental disorder? What should happen when health staff want half-a-dozen prisoners out of their cells for some group activity, and security staff say they cannot do that without three officers - who are not available? How can prison officers be expected to understand the mental disorders of the men they are looking after, if generally they have no psychiatric training and are not even allowed to read their medical notes? How can health staff provide regular care when their patients are suddenly snatched from their surgeries and sessions because there has been an incident and prison officers are locking down the wing?
The diagnosis of mental disorder is difficult - and made more difficult by the possibility of prisoners trying to manipulate the system. Certainly, there is some manipulation: a prisoner at the Scrubs this summer repeatedly evaded his court appearances, because he knew that if he got into the prison van and cut himself - even superficially - the security company would refuse to transport him. It was a prison nurse - not an officer - with years of experience who told us that some prisoners manipulate the regime for preventing suicides: "Let them hurt themselves, let them cut themselves, it's their responsibility. I have stood outside a cell and watched an inmate tear up his clothes and make a noose and put it round his neck; And I've said 'Yeah? Go on then, do it'."
The bottom line is that, with difficult patients, poor resources, and the culture clash between security and care, prison staff can be stretched to breaking point by some of the people in their care. Look at what happened in September with Terry Moreton. He has a history of violent crime, including a serious attack on a teenage girl at a railway station, but he was in the Scrubs awaiting trial for a fairly minor offence. The Inreach team had spotted him and diagnosed him as suffering from bipolar illness (manic depression) as well as personality disorder and they had given him some medication. But he had stopped taking it. For several days, he had been thumping his head against his cell wall in B wing, and officers had opened an F2052SH form, which is kept for any prisoner who is deemed to be at risk of self-harm. That Friday night, Moreton ran out of tobacco, threatened to kill himself if he was not given some, assaulted his cellmate and barricaded the cell.
During the night, officers managed to get in and took him down to the seg. On Saturday morning, the senior officer came in and said Moreton did not belong there: only 48 hours earlier, the doctors had said his illness was so bad that he was not fit for segregation, and there had been no doctor on duty the previous night to "fit" him. He called healthcare and, before long, a doctor came along with the duty governor.
By now, Moreton had sharpened the end of a metal flask, which is used to give the prisoners hot water, and was threatening to slash anybody who came into his cell. The duty governor wanted him restrained. The seg officers said they could not do that: if he was not deemed fit for the seg, they would be guilty of assault if they restrained him. The doctor suggested he could now fit him, and so the officers went in.
Moreton was taken to the seg's safe cell and strip-searched. The doctor then suggested that he might not be fit for seg after all, which was bad news for the seg officers if it meant that they had committed an assault, but good news if it meant they got rid of him. Late that Saturday, Moreton was finally taken to the inpatient healthcare cells where he proceeded to tear the plastic lid off the toilet, break it into shards, wrap one of them in a torn shirt and threaten to slash anybody who came near him. He then smashed his sink, broke the water pipes and flooded the healthcare unit in two inches of water. The health staff now said he was, in fact, fit for seg and sent him back.
The following morning, an officer outside the seg saw him sharpening his breakfast spoon on the window. The senior officer persuaded him to hand it over. That night, Moreton made a dummy out of his bedding, hung it from the window and hid himself under the bed, apparently hoping to ambush any officer who came in. He spent the next day literally gibbering in his cell, while those in neighbouring cells threatened to kill him, because he had now kept them awake for three nights.
Seg officers were fed up with the healthcare staff. They felt their unit was being used as a dumping ground, that a solitary cell was the worst possible place for somebody who was mentally ill, that it was absurd that the man could be unfit for seg one moment and fit the next. Health staff were just as fed up. They, too, felt that their unit was being used as a dumping ground and that, although Moreton had a history of bipolar illness, he also suffered from a personality disorder - which was not treatable - and that it was the disorder, not the illness, which lay behind his behaviour. They explained that he lurched between being fit and unfit for seg simply according to whether or not he was taking his medication. And both groups felt they suffered from decisions made by night staff and weekend staff who were not equipped to make these decisions. The truth, of course, is that they are both right: they are both being used as a dumping ground; the whole prison system is.
For years nobody really bothered about the mental health of prisoners. Only four years ago, research published by the British Medical Journal found that no doctors who were in charge of prison inpatients had psychiatric training; that only 24% of prison nurses had mental health training; that patients were locked up for between 13 and 20 hours per day; that services for the mentally ill in prisons fell far below standards in the NHS; that patients' lives were restricted and access to therapy limited.
In the last few years, as the problem has grown into a crisis, the Prison Service has started moving the mountain. Three years ago, they published a joint report with the Department of Health, Changing the Outlook, which admitted: "There are too many prisoners in too many prisons who, despite the best efforts of committed prison healthcare and NHS staff, receive no treatment, or inappropriate treatment for their mental illness, from staff with the wrong mix of skills and in the wrong kind of setting." The Prison Service adopted the "principle of equivalence", that prisoners should have the same healthcare as any other NHS patient, and took the historic step of handing over the commissioning to local primary care trusts.
Since then, they have funded 300 community psychiatric nurses to work on Inreach teams, like the one in Wormwood Scrubs, providing a care-in-the-community service for prisoners; adopted the Care Programme Approach which should link their work with community teams before and after a prison sentence; and set up new screening for prisoners on their first night to do a better job of identifying mental disorder (the old system was found to be missing 75% of cases.) But can a prison pretend to be a hospital?
Some of the culture clash between care and custody can be dealt with. There is a new programme to teach prison officers how to spot the symptoms of mental disorder. In principle, the rules may be changed to allow officers to read some of the medical notes of their inmates, which are currently hidden from them on grounds of confidentiality. There is some hope that the new NHS computer system will reduce the number of prisoners who turn up with no medical notes.
But there are other problems. The Mental Health Commission last year warned of the limits of community care in a prison: "The prison 'community' cannot offer any real equivalent to the support and care available outside prison, and any assumed equivalence between prison and the community outside greatly underestimates the isolation and bullying of the mentally ill in prison and the stigma of mental illness in such a situation."
There are limits also to what can be done with medication in prison, because prisons cannot treat inmates against their will, which means that those who reject their medication can deteriorate rapidly. But, with few exceptions, we have found prison health staff are deeply opposed to allowing compulsory treatment in an institution which is not a genuine hospital: the risk of accident and the temptation for disciplinary prescribing are too great. The Mental Health Commission last year said it was "deeply concerned" about the "extremely serious risk" of unrecognised or unchallenged coercive treatment in prisons.
Beyond that, it is hard to see how prisons will find the cash to reverse years of neglect, and there is a real fear among governors that the Treasury has stored up trouble by failing to ringfence future funding for prison health, leaving primary care trusts free to divert the money to patients who are more popular than offenders. The treatment gap will not be closed, and yet the problem will persist.
Prisons are the wastepipe down which other institutions send their rejects. The flow of mentally disordered men and women into custody is being pumped not simply by the failure of the Department of Health to organise effective care in the community. Within the criminal justice system, the police and the courts have special systems to divert the mentally disordered. They don't work.
Police can remove them to a place of safety for 72 hours for assessment - but only if they are in a public place and not if they are being charged in the police station, and only if their illness is recognised by the officers and not if it involves drug abuse, and only if they are in immediate need of care and control and not if they are merely ill, and only if the police have time to go through the procedure rather than simply processing them for court.
The courts, too, have powers to send people to prison or hospital to be assessed - but only if they are told that a bed is available. In 1990/1, all the courts in England and Wales between them used this power only 412 times. Since then, despite the massive increase in the charging of mentally disordered people, they have used it even less: in 2000/1, they sent only 168 defendants to be checked for mental illness. Two years ago, the Home Office studied its court diversion schemes and found that "many schemes are currently ineffective" - patchy in geographical availability, peripheral to local psychiatric services, poorly designed, "inadequately supported" by local hospitals and "unpopular with local psychiatrists". Juliet Lyon, director of the Prison Reform Trust, said this year that the network of 136 schemes had "virtually fallen apart".
So, at a prison like Wormwood Scrubs, they can find themselves dealing with a man like Manuel York who was agitated, unpredictable and hallucinating sounds, visions and physical sensations. A visiting psychiatrist at the prison immediately recognised that he was profoundly disturbed and diagnosed hebephrenic schizophrenia, a particularly disorganised version of the illness. And yet that man, who had been arrested for making unwanted phone calls to a woman, had passed straight through the police and the courts without anybody stopping to ask if he was ill, let alone diverting him for treatment.
And the failure is repeated when it comes to their release. There was a man at the Scrubs recently who tried to hang himself three times in a week; he also bit, punched and spat at staff. Then he left the prison - and nobody knows where he has gone. Research two years ago found that 96% of mentally disordered prisoners were put back into the community without supported housing, including 80% of those who had committed the most serious offences; more than 75% had been given no appointment with outside carers. And yet Department of Health policy requires all mentally disordered prisoners to be given a care plan on release.
When the Home Office researched mentally disordered defendants in court, they found that: "The majority were not career criminals who had become mentally ill. Most appear to have offended in the context of mental illness and social exclusion, having fallen through gaps in community care." When the Home Office recently reviewed the care of those men and women in prison, the researchers concluded by quoting an earlier survey: "It seems that mentally ill offenders will be as much at risk from society, as they will be a risk to society." The white prison vans still roll up outside the prison gates.
Read part one here
· To protect medical confidentiality, names and some identifying details of prisoners have been changed.
· Additional research by Roxanne Escobales
Mental disorder includes
· Mental illness such as psychosis or severe depression, often occurring as an episode in an otherwise healthy person and liable to respond to treatment
· Personality disorder, such as antisocial or paranoid, occurring as a continuing pattern of abnormal behaviour, sometimes the result of childhood experiences, generally difficult to reverse
· Neurotic disorder, such as anxiety and phobias, occurring at a level likely to interfere with normal activity, generally amenable to treatment
· Learning disabilities, usually involving significantly impaired intellectual functioning
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