In January 2016 the Prisons and Probation Ombudsman (PPO) published their review on the state of mental health services within prisons; Learning from PPO investigations: Prisoner Mental Health. The review is based upon the lessons learnt by the PPO through its independent investigations into deaths in custody between 2012 and 2014, and more specifically those instances where the deceased had been identified as having mental health needs before their death. Throughout the report, the PPO identifies a number of lessons to be learnt which aim to ensure that there is a consistently high level of care afforded to those affected.

Within the report, the PPO explores a number of themes recurrent within the investigations. These are broadly categorised into two sections: the first relates to the identification of mental health problems and the second the provision of mental health care.

Identification of mental health problems

In this section of the report, the PPO addresses a number of concerns relating to correctly identifying mental health issues. These concerns include poor information sharing, a failure to make referrals, inappropriate mental health assessments, and inadequate staff training. The PPO highlights a range of procedural and practical steps which should be implemented and followed by the prison service to minimise these concerns.

The PPO recommendations include:

  • Concern about the reception screening process on arrival at prison. In particular, an over-reliance by staff on the prisoner providing information and how they present it at the time, rather than a consideration of documented risk factors.
  • All staff should be competently trained in the use of information services such as SystmOne and, further, should ensure that an adequate handover of information takes place from prison to prison, and between prison healthcare teams and services in the community.
  • The need for a clear and consistent system for making mental health referrals, including a distinction between standard and urgent referrals.
  • Training for prison staff in relation to mental health awareness. The review commented that training can be poor, if not non-existent, and as a result staff are sometimes unable to recognise and manage symptoms.
  • Those assessing mental health should utilise all resources available and take into account all relevant information. They should also use standard mental health assessment tools and ensure compliance with NICE guidelines.

Provision of Care

In this section of the report the PPO highlights the need for an effective care plan to deliver appropriate treatment, medication and support. Again, a number of concerns were addressed relating to information sharing. The review highlights the need for healthcare staff to liaise effectively with prison staff in order to help them protect the prisoners under their care. Prison staff are heavily involved in the day-to-day management of prisoners with mental health problems and it is imperative that relevant information is shared (within the boundaries of patient confidentiality).

In addition to this, different healthcare teams should work together to ensure that an accurate diagnosis is made, and appropriate treatment is provided. This includes both primary and mental health teams, but also instances of dual diagnoses whereby the prisoner suffers from alcohol and drug misuse problems as well as mental health issues. In such situations each of his/her needs should be supported simultaneously and in a co-ordinated manner. Adopting this approach would minimise the potential for conditions to be treated in isolation and ensure care is delivered in the most effective way possible.

Effective procedures should be implemented relating to those prisoners subject to an ACCT. It is imperative that a multi-disciplinary approach is adopted and that all relevant people involved in a prisoner’s care (including healthcare representatives) are involved in ACCT reviews. Additionally, care maps should be adequately updated and reviewed as new issues arise.

Finally, the review considers the difficulties inherent with treating patients who suffer from personality disorder, those who require transfer to a secure hospital, and those patients who are non-compliant with their medication.


In short, although the review recognises the ‘excellent work that is carried out by many prison officers and healthcare staff,’ it concludes that too often there are instances of poor communication and disjointed care. The report emphasises that a more integrated and collaborative approach should be adopted, and that all healthcare and prison staff should be adequately trained in mental health awareness. Such an approach should ensure an effective system of care for prisoners and, it is hoped, provide significant improvement.

The full report is available online.